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Taking a Proactive Approach to Retroactive Changes from CMS

The volume of changes CMS makes to its policies and pricing schedules every year is staggering, with over 600 retroactive changes anticipated for 2023 alone, making it challenging for payers who depend on outdated technology to keep up. To capture the changes, Payers must comb through manuals, fee schedules, bulletins, and news flashes. Once the changes are identified, IT resources typically have to upload them into the payer’s ecosystem in multiple places.

For example, if a new modifier is posted for Medicare, teams must figure out which claims are impacted and what impact those changes may have. Then, they must determine what actions should be taken: overpayments that may require recoupments or underpayments that may surface during a CMS audit or spark a series of calls from providers, all contributing to provider abrasion. And the same process must be followed for changes at the state Medicaid level, which can be even more taxing and time-consuming since each state is unique.

Managing CMS policy and fee schedule changes is an enormous burden on everyone. Most payers have entire teams of business and technical resources dedicated to reacting to these changes.

However, at HealthEdge Source™, we are actively working with our customers to solve this problem using modern, prospective payment integrity solutions. We’re enabling payers to take a proactive approach to retroactive changes with Source Retroactive Change Manager.

Because the pricing and editing data is in a single instance, Source can automatically identify and assess which claims are impacted by the changes and capture the price/policy used when the claim was processed. Knowing the new price/policy, the system can then analyze the impact of the retroactive changes and help business leaders easily understand potential risks for over/under payments.

The Results Speak for Themselves

The Source Data Study team recently completed a study with a regional plan with home and host capabilities. The Source Retroactive Change Manager evaluated 67,916 claims from Q1 2023 and identified $2.67M in overpayments. The health plan was also able to use the solution to reduce several administrative burdens and costs, including:

  • Automate timely identification, repricing, and reporting of retroactive changes
  • Remove contingency vendors
  • Ease provider abrasion
  • Improve compliance
  • Reduce waste

A separate regional health plan with 200K+ members was looking to strengthen confidence in its pricing accuracy, compliance, and readiness for external audits. In a 90-day study, Source Retroactive Change Manager identified 95,830 claims with pricing changes, resulting in over/underpayments totaling $20,921,901.

For more information on how Source can help your organization take a proactive approach to retroactive changes to CMS policies and prices, listen to this webinar, “Preparing for CMS Updates and Retroactive Changes,” presented by Jared Lorinsky, chief strategy officer, and Carl Anderson, senior product manager for HealthEdge Source.