Medicare Claims Editing Module Increases Revenue by 25%

When health plans have finalized claims, they don’t want to retroactively fix them. It is vital to a health plan’s success to improve claim accuracy and reduce errors.

An IT ecosystem that can integrate easily and exchange data in real-time is essential for health insurance companies to improve claim accuracy. With real-time data, payors can match members with benefits plans and providers with contract provisions, ensuring claims are paid accurately. The improper use of data matching tools can drain payers’ time and resources and negatively impact their bottom lines.

Claims Editing

Therefore, payers and TPAs are always looking for solutions that enable them to create flawless data reports, maintaining the interest of stakeholders. By using the CMSPricer Edit module, they can generate reports that are in accordance with real-time CMS regulations and ensure that claims have been validated before submission. You can automate this process. As well as preventing downstream denials and delays, automated validation ensures that payments are made on time.

In CMSPricer, editing operations are automated using APIs.

The following fields can be edited:

  • Professional (CMS 1500) and Institutional (UB04) CMS rules
  • Diagnosis Code Validation
  • Local Coverage Determination (LCD)
  • National Coverage Determination (NCD)
  • Age Edits
  • Age Edits
  • Outpatient Code Edits (IOCE)
  • Medically Unlikely Edits (MUE)
  • Correct Code Initiative (NCCI)
  • CPT and RVU Edits
  • Modifier Edits
  • Advance Beneficiary Notice of Non-Coverage (ABN)

With CMSPricer’s editing module, erroneous claims can no longer be rebilled, accounts receivable days are reduced, coding compliance is improved, medical necessity problems can be identified and corrected before claim submission, and errors can be tracked in real-time.

Consequently, claim denials can be reduced, clean claims can be submitted, speed to revenue can be accelerated, AR days will be reduced, the average cost of reworking a rejected professional claim will decrease (ranging from $10 to $25), and edit updates will be automated so that they reflect in your billing system. All updates are automatically pushed by CMSPricer using an API.

That sounds interesting, right? Let’s see CMSPricer in action.