How Medicare Claims Editing Save You from Claims Denials?

When it comes to controlling healthcare costs, and keeping employers and providers satisfied, payers play an important role. They balance these competing objectives through processing of medicare claims as efficiently and precisely as possible. 

With rising healthcare and profits getting stagnant, payers need to make sure medicare claims processing is flawless. Any errors in claims processing result in a series of expensive problems, which could be like inaccurate and inconsistent evaluation of claims, penalties for regulatory noncompliance, unnecessary overhead, and litigation expenses among others. All the more, the ability to attract and retain participating providers depends largely on how quickly and accurately payers process and settle claims and submit claims in compliance with CMS repricing at Medicare rates and edit errors, if any. 

How Medicare Claims Processing Works

  • Clearing houses process medicare claims through medical editing solutions before adjudication
  • Organizations aggregate provider claims
  • Editing solutions ensure the claim is clean and paid as per CMS medicare policy rate schedules 
  • The objective is to ensure accuracy and limit over or under payments whether it is the need of organizations or facility claims with multiple specialists submitting charges on one hospital claim. 

    What Challenges Payers Can Face

    When edits to a medicare claim result in over or under payments, claims are denied and referred to further investigation. Providers will want to know the reason for the edits and failing to substantiate them could put the payers at risk for costly appeals and even litigation may ensue. Many often, legal challenges force various health plans to reopen claim appeals, pay physicians for previously denied claims, and update their systems to provide transparency regarding rule sources and appeals procedures. That’s why it’s simply a good practice to stay transparent into edit sources so that every stakeholder is satisfied that they are being treated fairly. 

    What is the Solution? 

    Medicare claims editing vendors used to compete on proprietary edits based on their interpretation of coding. But with the increasing demand for standards and accountability, today’s best practice is to base edits on CMS editing tools to clearly document, comply and explain edits in the language that providers understand easily. 

    Why CMSPricer?

    CMSPricer offers an affordable medicare claims editing solution that can analyze a claim, identify any edits if required, and perform and deliver results quickly, efficiently, and accurately. Let’s check what claims edits you can perform. 

  • Diagnosis claims validation
  • Local coverage determination (LCD)
  • National coverage determination (NCD)
  • Gender edits
  • Age edits
  • Outpatient code edits (IOCE)
  • CPT edits 
  • RVU edits
  • Modifier edits
  • Correct code initiatives
  • Introduced with an edit-only approach, this module of CMSPricer, a SaaS-based medicare claims editing API interface, is built to work fast, scale to its optimum use, and customize configurations to switch “on/off” specific edits whenever required. A built-in configuration form that comes as a part of CMSPricer portal is easy to manage and user-friendly. 

    Want to learn how this SaaS-based medicare claims editing portal CMSPricer works? Grab an opportunity CMSPricer is offering their new users to test drive 5 medicare claims editing for free, without any obligation!