MEDICARE PAYMENT INTEGRITY

Medicare is 20% of all US Healthcare expenditures and covers more than 16% of the population.    Medicare claims volumes are up to 3X that of commercial health plans.  Payment Integrity and management of associated administrative costs is more critical than ever before.

Protecting Enrollees at a Reasonable Cost

On average over 40% of a hospital’s revenue is derived from Medicare. CMS has shown their clear intent to enforce payment integrity in Payers and Providers. Commercial claims editing and EHR systems have proven ineffective at meeting the needs of the healthcare community.

To compound the issue, the Medicare member pool is expanding quickly.  Medicare’s influence on the US Healthcare system increases every day. More federal programs and commercial plans are using Medicare as a basis for compliance and pricing.  Given the 3X claims multiple, volumes are growing rapidly.  All of this makes Payment Integrity more difficult to manage. 

The Context real-time, cloud based Payment Integrity Platform provides comprehensive tools including:

  • Pricing leveraging UCR and all 16 Medicare Prospective Payment Systems to facilitate pricing and integrity checks
  • UCR for Medicare gap pricing
  • Advanced Medicare and Commercial analytics logic to assess payment compliance at a granular level

Contact Us - Medicare Solutions


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