ALEXANDRIA, VA – Health plan SummaCare and Medicare administrator First Coast Service Options have selected Burgess’ Medicare pricing software to support their Medicare contracts.

Health plans are looking for software solutions to deal with the increase in audits and appeals in pricing disputes, as well as the continued complexity of Medicare reimbursement, said Greg Burgess, president and founder of Burgess.

The Centers for Medicare and Medicaid Services, or CMS, is publishing more frequent updates, which is making it more difficult for health plans to manage. The increase of incentives and legislation addressing Medicare operations are also adding to the burden, Burgess said.

“Medicare pricing is an art,” said Janice Young, program director for Health Industry Insights. “Outsourcing makes some sense because it is relatively standardized and used across all Medicare plans.”

Congress sets out the statutory framework for Medicare reimbursement, and the Centers for Medicare and Medicaid Services, or CMS, implements the system within the statute, a CMS spokeswoman said.
The agency recently overhauled the Medicare payment system for inpatient stay to ensure payment accuracy, she said.

“Streamlining is a matter of efficiency, and certainly we don’t want to be inefficient,” she said. However, streamlining at the expense of accuracy is not one of CMS’ goals. “Our goal is to pay accurately and remove any incentive other than the incentive to provide high-quality care.”