What is the Prime Purpose of Medicare Repricing?

Medicare and Medicaid repricing systems make healthcare payers capable to efficiently manage healthcare provider data and automate claims pricing by leveraging its adaptive, rules-driven architecture. Medicare claims repricing’s purpose is to reduce, pre-negotiated rates to providers in the healthcare networks. 



What is Medicare Claims Repricing? 


Medicare claims repricing refers to the application of the contract terms to the billed charges. Contract terms mean the contract between the hospital system or physician practice and the insurance network.  The billed charges are from the hospital system or the physician group.

 

How Does Medicare Claims Repricing Work?

There are numerous ways for Medicare claims repricing. Many claims repricing strategies are there for different types of plans. The preferred provider organization (PPO) for health insurance claims repricing is among the most commonly used solutions. In this solution, a fixed fee structure is applied to medicare claims to enable providers to reconstruct and discount payable claims. This method effectively remittances efforts.

Repricing Explained:

After receiving a Medicare claims form, the health insurance companies adjudicate whether the person is eligible, or the service or record service has eligibility, whether it is too late for timely filing or needed prioritization, etc. Then, it requires to be repriced, as the original claim gets the billed charges on it, and then repricing is needed to the allowed amount. 

Contract Terms:

The Medicare repricing is done on the basis of case rate, percentage of charge discount, per diem, or what the insurance companies reimburse a set amount or expense per day. A specific line of payment is carved out. The total amount of expenses should be within the allowed amount.

Billed Charges:

Then comes the billed charges. This is the fictional amount that nobody pays. So the group charges of this amount get confirmation through the charge master. It is a list of all of the prices of every single service at the hospital, such as 30-minute overstay costing $1000 bucks, etc. and all these add enough for the formation of the billed charges.

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