Milliman’s Medicare Repricer software assigns Medicare-allowable fees to administrative claims data, allowing payers and providers to surface those fees in their enterprise data warehouse. The software includes service-line level detailed claim adjudication outputs and a suite of reporting workbooks to assist with validation and reconciliation. The Medicare Repricer includes inpatient, outpatient, Ambulatory Surgical Center (ASC), and professional claims repricing capabilities, and replicates the Medicare claim adjudication logic including diagnosis-related group (DRG) and ambulatory payment classification (APC) grouping.

Uses of Medicare Repricer

The Milliman Medicare Repricer software has a wide variety of applications, including:

• Reference price: Percentage of Medicare comparisons provide easy to understand price relationships.
• Standardized fee schedules: Calculating providers’ current percentages of Medicare makes it easy to switch to Medicare-based fee schedules.
• Capitation fee-for-service equivalents: By repricing data to Medicare-allowed amounts, payers and providers can better understand the value of the services delivered under a capitation contract.
• Payment integrity: Independently repricing claims experience to Medicare-allowed amounts enables plans to check actual payment amounts and adjudication results.

Supported fee schedules

• Acute Inpatient Prospective Payment System (Acute IPPS)
• Hospital Outpatient Prospective Payment System (OPPS)
• Ambulatory Payment Classification (APC), (part of OPPS)
• ASC
• Skilled Nursing Facility Prospective Payment System (SNF PPS)
• Physician resource-based value scales (RBRVS)
• Durable Medical Equipment and Prosthetics (DME-POS)
• Clinical Lab
• Ambulance
• Average Sales Price (ASP)
• Parenteral and Enteral Nutrition (PEN)
• Splints and Casts payment limits