Improve Healthcare Decisions With Medicare Claims Repricing

Healthcare costs are on the rise, and employers are struggling to keep up by finding high medical claims, minimizing them, and understanding how they affect the health plan. As a result of low transparency and complicated relationships among employers, brokers, and bidders, it is increasingly difficult to accurately compare costs across health plans and networks.

What is Claims Repricing?

Repricing medical claims is a solution to this problem. Through the use of a third-party actuarial expert and a systematic, objective analysis, a fair comparison can be achieved.

Comparing medical claims cost repricing based on actual claims data allows clients to pick the network that contains the lowest costs. The goal of repricing is to identify the network that provides the best coverage at the lowest cost. It can also be used to evaluate more traditional networks in addition to reference-based pricing.

Medicare Claims Repricing

Why Claims Repricing?

Medical claims repricing allows clients to compare medical claims costs across different health plans and networks. It makes it easier for clients to determine which option is best for them. Repricing allows for an objective and actuarially sound comparison of claims costs across different networks.

Providers reprice each procedure per their contracts in order to conduct an accurate repricing analysis. Providers providing aggregate analytics without taking the client’s experiences or demographics into account typically provide aggregate analysis in the absence of clear instructions. Thus, the results that providers self-report are usually misleading since they are often apples to oranges.

Client Challenges

People often look understand if their carrier rates were competitive:

  • Can reference-based pricing (RBP) reduce costs?
  • Is it worth switching to a new carrier?
  • How does performance differ by state and major service category?
  • CMSPricer Approach

    CMSPricer is a SaaS-based Medicare repricing system designed for payers, PPOs, TPA’s, BPO’s, self-funded employers and auditing firms. By using the CMSPricer tool, they can assist their clients with choosing the right network and providing clients with an independent actuarial repricing analysis by region and major service category. 

    Claims Data Accuracy & Compliance

    CMS’s policies and rates are constantly changing. CMSPricer is constantly monitoring CMS for changes, and because its software is a SaaS-based solution, it is the only Medicare claims repricing solution that requires no regular software maintenance. With CMSPricer, all PPS types of institutional and professional claims, including claims editing for Reference-Based Pricing, will be priced accurately for Medicare.

    The CMSPricer system supports Medicare and Medicaid claims repricing and safeguards PHI (personal health information) and claims data. With 2048 bit encryption (the strongest on the market) and an EV SSL Certificate (the most advanced on the market), it is the best cloud-based security solution available today. CMSPricer is HIPAA and ANSI 837 version 5010 compliant, providing secure login and account security to all users.

    To Sum Up:

    The CMSPricer platform is designed using the latest techniques and interface methodologies to ensure a smooth implementation into any company, including payers, PPOs, TPAs, BPOs, self-funded employers, and auditing firms. CMSPricer works in the background while payers and providers conduct their daily business, finding ways to increase the efficiency and effectiveness of their delivery models. 

    What’s the latest in Medicare claim repricing and management? And what are the innovative trends driving the evolution of the industry? Visit our blog to stay up to date.