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CLAIM PRICING

Milliman Medicare Reference Pricer

Medicare pricing on demand

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The challenge

Implementing Medicare pricing is costly and resource intensive

You need a pricing solution that meets provider contract requirements, but Medicare’s patchwork of fee schedules and groupers are complicated, and may not be appropriate for all scenarios. This can lead to delayed updates and the inability to trace pricing results back to current Medicare policies, costing additional resources and time.

The solution

Leverage flexible and up-to-date claim pricing

The Medicare Reference Pricer provides complete and up-to-date Medicare payments with the flexibility to extend Medicare to commercial and individual claim pricing. Now, you can easily adjust payment components and relativities, as well as extend pricing to non-Medicare covered services and percent of Medicare reimbursement provisions. The software can be deployed as a web service or as a batch process, and is integrated into the web-based claims examiner support system.

BENEFITS

Milliman Medicare Reference Pricer benefits

Reduce costs

Realize the results of your pricing strategy by freeing yourself from legacy contract structures and systems.

Standardize payment using Medicare

Simplify payment structures and processes for individual, commercial, and Medicare Advantage with the flexibility needed to capture contract nuances.

Ensure Pricing Accuracy

Medicare payment rules are complex and change over time. Frequently, adjustments must be applied to the fee schedule rates published by CMS for accurate pricing. The Medicare Reference Pricer is updated automatically and applies appropriate fee schedules and adjustments based on the claim service date.

Stay current

Receive timely updates with the latest information from Centers for Medicare and Medicaid Services (CMS) to keep payment systems up to date.

Customize configuration

Choose the payment systems and components that are relevant to your network contracts and providers.

Achieve a transparent cost network

Reap the benefits of standardized payment structures and processes, including easy to understand provider reimbursement relationships and reduced administrative costs.

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FEATURES

Milliman Medicare Reference Pricer features

Live medical claims pricing

Adjudicate claims quickly using Medicare fee-for-service payment methodologies.

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Flexible integration

Use Medicare Reference Pricer as a stand-alone pricing module, or seamlessly integrate it with your current claim system.

Customizable data

Select alternative payment weights for maternity and newborns, enable extended fee schedules for non-Medicare covered services, choose the outlier pricing methodology, and set your own fee schedule update calendar.

Integrated groupers

Use integrated groupers for Medicare-severity diagnosis-related group (MS-DRG) and ambulatory payment classification (APC) — plus code editor functionality — for accurate and efficient grouping.

Accurate data

Rely on pricing systems tested against Milliman’s full Medicare FFS fee-for-service (FFS) data feed from CMS.

Milliman support

Rely on high-touch support from experts in Medicare payment systems and provider reimbursement.

SERVICES

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PRODUCTS

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