Self-Funding: What Does Medicare Claims Data Have To Do With It?
It is typical for small employers to pay 8% to 18% more for the same plan than their larger counterparts.
To reduce some of these costs, employers have moved to a self-funded model for benefits. Because of this, it is becoming more and more important to have accurate claims data in order to create a plan that is both cost-effective and supports employees.
Accurate, Timely Benefits Claims Data is Possible with CMSPricer
CMSPricer, a SaaS-based Medicare Repricing System, is focused on eliminating the challenges of complying with the latest CMS policies and rules seamlessly and reducing the friction of benefit information that limits choice and adds costs. In addition to providing accurate, real-time Medicare claims repricing data and strategies for Reference Based Pricing, CMSPricer has helped TPAs and self-funded employers provide more customized, profitable recommendations to their clients and themselves.
What is Claim Repricing?
In theory, claim repricing is easy, but in practice it can be challenging. Payment rates are applied to healthcare billing charges according to a contract or agreement.
A claim is submitted by the provider that includes each line item for the services provided. Based on the agreed-upon rates, the payer evaluates the validity of the claim. A patient is responsible for paying the provider an allowed amount, which is divided into the responsibility of the patient and the plan.
An agreed-upon rate can be a signed contract or an agreement that is similar to Medicare’s episodic payment method. If a provider accepts a patient and their insurance, he or she agrees to adhere to its payment policies.
Repricing Claims: The Other Side
Pricing for a Medicare Advantage plan seems simple until a patient enrolls. Medicare Advantage is a Medicare plan delivered through a private insurer that is growing in popularity. Despite not having a contract with the private payer, the provider might still accept Medicare patients. Two payment types would be available in this situation.
Providers who are not contracted with payers typically receive episodic payments from Medicare. Contractual relationships may affect the reimbursement rate. Per-visit payments have historically been made using a fixed rate per line item in many contracts.
Remittance advice is the end result of this process, which can be difficult for providers to interpret.
For episodic payments, the remittance advice typically includes reversals of billed charges plus episodic amounts along with any usual adjustments, such as sequestration and patient responsibilities. Every payer, however, has a different system for adjudicating and paying claims, causing the remittance advice to differ.
CMSPricer Helps TPAs and Self-Funded Employers Handle Claim Repricing Confusion
Due to the differences in Medicare claim repricing presented by all payers, it is imperative that providers communicate with payer representatives about their payment processes. By leveraging the solutions in CMSPricer, you will spend less time analyzing remittance advice because your organization will be paid the correct amount for all services provided.
CMSPricer offers an easy-to-use SaaS-based Medicaid & Medicare repricing system to help TPAs and self-funded employers manage claims better. Payers, PPOs, TPAs, BPOs, self-funded employers, and auditing firms can utilize this platform to get paid faster and alleviate their workload.
Get in touch with us to learn more about how our Medicare claims repricing system can give you leverage and save an average of 90% on Medicaid and Medicare claims each year.