Payers Can Avoid Redundancy in Rebilling Error-ridden Medicare Claims By Using CMSPricer

The Medicare Administrative Contractors (MACs) report periodically the most common claims errors they encounter. A few examples of the error-driven Medicare claims that occur on claims are as follows that MACs send to the payers.

  • The claim is duplicate in nature.
  • The primary identifier of the referring physician is missing or incorrect.
  • Invalid or inconsistent place of service code (POS).
  • The message from MAC could be like the payment or processing of the claim is not possible without missing information. This claim contains incomplete or inaccurate information, and you do not have any appeal rights since it cannot be processed. We request that you submit a new claim that contains correct information.

    CMSPricer Repricing System

    Why Do These Errors in Medicare Claim Processing Happen?

    Code complexity, continuously evolving CMS rules almost every single day, and regulatory changes have complicated the Medicare claims’ rate processing for the payers. If there is any compatibility issue with the codes, CMS rules, diagnosis code validation, and so on, payers or their organizations would receive messages from MACs asking for fixing the errors and if such incidence tends to happen continuously, that would delay the outcomes that the end-users are looking for.

    How Does CMSPricer Help Payers Save Redundancy in Billing and Reduce Denials?

    CMSPricer – a SaaS-based Medicare claims repricing and editing system with a robust and easy-to-use interface – offers its users an automated solution to validate their claims before they are generated and submitted to payers. As a result, they can avoid downstream denials and delayed payments, thanks to the CMSPricer editing solution which is fully automated via API.

    The amazing part of using CMSPricer Medicare claims repricing and editing system is that you can edit your entries multiple times, recheck and generate submission reports until you get the right one.

    How Do These Edits in the CMSPricer System Work?

    Sign in the system dashboard of CMSPricer to see what the edits could entail. Those are as follows:

  • Diagnosis Code Validation
  • Professional (CMS 1500) and Institutional (UB04) CMS rules
  • National Coverage Determination (NCD)
  • Local Coverage Determination (LCD)
  • Outpatient Code Edits (IOCE)
  • Age Edits
  • Correct Code Initiative (NCCI)
  • Medically Unlikely Edits (MUE)
  • Modifier Edits
  • Advance Beneficiary Notice of Non-Coverage (ABN)
  • CPT and RVU Edits
  • In short, the editing system will enable its users to easily identify missed revenue opportunities, clean claim/first past submission rate of >98%, and many more.

    Why Should Payers Leverage Medicare Claims Editing Solution of CMSPricer?

    As said already, there are so many reasons to take advantage of using CMSPricer when it comes to producing error-free Medicare claims. CMS Pricing is designed to help increase the first pass through rate for claims when working the revenue cycle.

    More importantly, you will be able to avoid the redundant work of rebilling erroneous claims, reduce accounts receivable days, identify and resolve medical necessity issues before claim submission, increase correct coding compliance, and receive real-time information on identified errors.

    In Conclusion:

    You will, therefore, be able to reduce payment denials, speed to revenue and AR days by detecting rejections before they reach your EDI clearinghouse, saving you an average of 24 days of waiting for rejections and making corrections. With the CMSPrice Medicare Claims Editing Module, you will also be able to reduce costs: the average cost of re-working a rejected professional claim ranges between $10 and $25. Your billing system is automatically updated to reflect edits: You don’t have to track down CMS changes, learn coding initiatives, etc. Updates are pushed through APIs automatically.