Modernizing and Innovating Medicare Claims Repricing Process

The Medicare Advantage market is expanding, giving out plenty of opportunities for insurers. Driven by an aging population and an increasing preference over fee-for-service plans, Medicare enrollment is on the rise. It is expected even more to grow from 35% of Medicare members to between 45-55% by 2025.

And, this isn’t just growth in the number of enrollees, revenue is also getting a boost, which is predicted to increase by 7-9% annually! It means the market is potentially attractive and there are many Medicare Advantage market players who are equally interested in it.

So, now is the time to expand your product offerings and capture more market share. But the sorry picture is, scaling your operations has proven more challenging than expected. Wondering what is the reason, right? It is your manual process to create and manage the benefit plan materials, the broken workflow that might have been holding you back.

If you are like most organizations managing them manually, you are also most likely to end up making a chain of errors in the process and that process might be a heavy burden on your teams to complete the process of repricing claims, complying with the updates on time. That would cost you and errors in outputs would cost you even more dearly.

This is often seen as the barrier to the expansion of Medicare Advantage organizations who simply cannot add more hardships to the workflow of their Medicare claim repricing teams.

So, what to do? They need to modernize their process of Medicare claims repricing.

Process Modernization:

The Medicare market players are mostly lying on a bed of paper. As a business that revolves around services and contractual agreements, this paper-intensive process tends to make a chain of errors, output misleading results too. So, it’s time for them to go digital, and ditch paper, and transform into a streamlined anywhere, anytime type of solution.

Go for SaaS Based Process:

SaaS based process for repricing provides an intelligent, purpose-built and automated platform that can significantly reduce the time and effort required to create, update and estimate Medicare PPS payments. It can automate the process and address process complexities, such as hospital acquired conditions, MS-DRG grouping, NUBC guidelines and Medicare Code Edits (MCE).

A SaaS based CMS repricing system can automatically incorporate your plan data upon your inputs from the database and eliminate your need to perform any changes manually. That leads your team through a fully guided, intuitive process for entering custom plan information.

A New Way Forward:

Regulatory requirements are increasingly driving payers and Advantage players towards technology transformations. It is a pressing point for them to improve their data systems, but at the same time, it is giving them an opportunity to increase service quality and precision.

Are CMS PC Pricers the Standard?

To be specific, NO, because of the delays inherent within the release schedule. As per CMS itself stating on the website, “The final payment may not be precise due to the fact that some data is factored in the PC Pricer payment amount that is paid by Medicare via provider cost reports.” Aside from that, variance between actual Medicare payment and a PC Pricer estimate may exist due to a 3-month lag in quarterly updates to provider data.


CMSPricer can eliminate all your worries and expensive hassles of Medicare claims repricing. This SaaS based solution meets all stringent CMS Medicare claims accuracy requirements for auditing claims from over 50 Medicare Advantage plans. By using the CMSPricer SaaS based tool and interface, you can effectively batch processes with ease and precision and import and export claim files for repricing so easily with the custom interface you can choose.

See four more exciting benefits CMSPricer users can obtain from it by clicking here.