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OPPS Claim Headaches
Are you frustrated because you have no way of calculating the Medicare OPPS payment amount for outpatient hospital claims?
Help Is Finally Here.
Are you frustrated because you have no way of calculating the Medicare OPPS payment amount for outpatient hospital claims?
Help Is Finally Here.
APC Pricer is an OPPS reimbursement calculator used to determine the expected reimbursement for outpatient hospital claims using CMS’s Outpatient Prospective Payment System (OPPS).* APC Pricer is simply an OPPS Pricer.
APC Pricer is unique because it takes into consideration multiple procedure discounting, comprehensive APC payments, procedure packaging, outlier payments, composite APC payments, and many other features to accurately calculate the OPPS reimbursement amounts.
* APC Pricer processes claim information as provided and payment amounts shown do not take medical necessity, CCI edits, I-OCE edits, or MUEs into consideration.
APC Pricer is a stand-alone Excel based OPPS Pricer that allows you to determine the OPPS reimbursement amount for an entire outpatient hospital claim (not just individual services). It resides on your PC and requires no special software.
APC Pricer is 100% HIPAA compliant because all information is fully encrypted and NO Protected Health Information (PHI) is saved into APC Pricer.
Many payers now reimburse outpatient hospital claims using OPPS.
To properly manage your hospital’s AR, it’s vital that your revenue cycle team have the ability to determine the expected reimbursement for all outstanding claims.
Knowing the expected reimbursement makes them more efficient and has the following advantages:
Increased Revenue. Calculating the expected reimbursement of your OPPS claims upfront gives your billing and collection team the knowledge to know if a claim is paid correctly. If not, it can be appealed quickly for better cash flow.
Increased Efficiency. Knowing your OPPS claims actual reimbursement amount allows for the accurate adjustment of claims to their net value.
Increased Accuracy. Correct contractual allowances enable your finance team to value your AR more accurately resulting in more precise financial reporting.
Medicare Advantage plans are allowed to pay providers the Medicare allowable amounts for services provided to their members.
CMS regulation 42 CFR §422.214 Special rules for services furnished by noncontract providers states:
“Any provider (other than a provider of services as defined in section 1861(u) of the Act) that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-forservice plan must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.”
Using APC Pricer gives you the confidence to know you’re paying claims accurately and within CMS’s regulations.
To calculate the OPPS reimbursement amount, you simply input claim information from your UB04 into APC Pricer.
APC Pricer does all the rest. It’s very simple to use and does not require OPPS knowledge.
LEARN MOREAPC Pricer© includes the following OPPS payment features:
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