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Repricing, Payment Integrity & Contract Modeling
Powerful, Innovative & Transparent
Since CMS's inception, the healthcare industry is facing one of its biggest challenges with the implementation of
proposed 2010 Rate Benchmarks. On average, Medicare will face a 4% payment benchmark reduction translating into a
roughly 3% decrease in payment. Additionally, constant change to Medicare regulations combined with unparalleled complexity has
created a very challenging environment most healthcare organizations have trouble navigating.
As a managed care technology innovation leader, we are proud to offer our Medicare solutions for repricing, contract modeling and
payment integrity audits. We are uniquely positioned to offer both Commercial and Medicare claims repricing capabilities that
allow our customers to model both methodologies side-by-side for accurate comparisons.
Whether you are a Health Plan, Institutional Provider, Physician or a healthcare technology firm, our innovative web-based solutions
will help you better manage your Medicare processes. Because Medicare reimbursement changes with great frequency, we
constantly monitor CMS for changes; and because of the unique nature of our technology, we have the only Medicare solution
on the market that does not require regular software maintenance. While there are a number of Medicare solutions on the market,
we are the only company to date that has created an integrated solution by combining Medicare functionality with industry’s most
robust commercial pricer for unparalleled flexibility and value to all stakeholders.
With our software you will be able to do the following:
• Estimate Medicare payment
• Compute actual Medicare reimbursement
• Assess if the payment is accurate
• Model Medicare reimbursement
• Compare Medicare reimbursement to Commercial contracts
• Compare Medicare reimbursement to Usual & Customary Charges
• Apply Medicare Groupers (DRG, MS-DRG, APC, etc…)
• Apply NCCI Edits
• Export fee schedules and other rate tables to production systems
• Seamlessly integrate Medicare reimbursement into your existing processes through our unique Service Gateway API
Currently we support the following Medicare programs:
• Acute Inpatient PPS (DRG)
• Outpatient OPPS (APC)
• National Clinical Lab
• National Physician Fee Schedules
• DME
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