Set up post-grouper custom pricing

Some state Medicaid and commercial Medicare-like plans use Medicare grouping methodologies but then override some of the reimbursement rules for certain status indicators or APC codes. Or, they simply pay at a percentage above Medicare. For claims reimbursement, you need to be able to model these kinds of adjustments.

NOTE: These instructions do not apply to actual Medicare contracts, only Medicare-like contracts from commercial plans.

When modeling contracts for commercial Medicare-like plans that use customized Medicare grouping methodologies, you can include adjustments to the CMS Outpatient calculation. For example, you can set rates for clauses and terms that use the CMS Outpatient calculation basis and adjust those rates as needed.

During the CMS Outpatient calculation, the system receives the results from the 3M grouping and pricing process and pulls the results into the voucher. You can adjust the voucher results as necessary for payment in the following ways:

• Adjust the CMS Outpatient calculation basis in the Rates window:
  • No Adjustment – No adjustment is made to the rates coming from the grouping and pricing process. This is the default selection.
  • Overall Percentage – Adjust the post-grouping and pricing rate by a specified percentage.
  • APC Status Indicator – Adjust the calc basis based on the SI.
  • APC code adjustment – Adjust the calc basis based on the APC code.
  • Line-item code adjustment – Adjust the calc basis based on the line-item code.