Health Insurance Claim Repricing

Claim Repricing is the Application of the Contract Terms Between the Healthcare Provider (Hospital, Doctor, etc.) and the Insurance Network to the BILLED CHARGES.

Billed Charges Are Submitted on a Claim by the Healthcare Provider to the Insurance Carrier. First that Claim is Adjudicated. Then the Claim is 'Repriced' per the Contract Terms.

Example of Those Contract Discount Terms Include 1) Case Rates, 2) Percent of Charge Discounts, 3) Per Diems, 4) Carve Outs and More.

The Final 'Price' After 'Repricing' is the Allowed Amount. The Allowed Amount is the TRUE COST OF HEALTHCARE. The Allowed Amount is then Split Between Patient Responsibility and What the Plan Needs to Pay.

Sources:

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#HealthcareCosts #HealthcareIndustry #ClaimsRepricing

[medschool]

Dude thank you so much, I just recently started working at a health insurance company handling benefits and claims & I tell you claims will be the death of me lol there’s so many things that can be wrong with a claim I’m so lost but I’m tuning into your videos and it’s so appreciated

[anujkhosla]

Very cool and easy to follow. Appreciate all your videos!!

[jdean]

I always appreciate your explanations of the basics, Dr. Bricker. I also share your videos with coworkers who I think can benefit from the knowledge you share. The more you

[randin]

Hello Dr. Do you have an updated 2022 /2023 video about repricing? I would love to get your expert knowledge about Multiplan and dataisght repricing out of network claims, and how to stop repricing. Thanks!

[cyrilsurendar]

Thank you sir, this is awesome and very informative. May I ask a quick question please ... Per your flow chart, the 'claims repricing' happens after the claims adjudication.

1) Are you saying after the claims is adjudicated it is then sent for repricing? I thought per your previous video on 'Claims Adjudication' the claim is paid, pended or denied. It now looks like before the actual amount can be paid to the Providers, it now needs to be repriced. Am some how not able to connect the relationship between claims adjudication and claims repricing. If claims repricing (allowed amount) is as per the contract between the payer and provider, should it not happen before the claims adjudication process, Can you please clarify?

2) Is claims repricing done by Health Insurance Companies or do they send them to another entity that specializes in claims repricing?

It will be great to get a response (or a video) on the above two questions.

Thanks again for the all the knowledge you share, sincerely appreciated.

[hutly]

I recently received a lab bill which two of the tests run were not covered but was done in-network, and I received the EOB that stated the entire bill was was reduced from lets say $800.00 to $60.00, the EOB included pricing for the things they did not cover. My lab sends me the bill for the full amount (the non-repriced) for $400.00, am I crazy for thinking that I should only be paying the repriced amount? The lab is saying they denied the claim for the two tests, which is fine..but shouldn't we only pay the full repriced amount, I've been OCD about this and I just can't understand why the lab would bill this way, seems ethically wrong. Well, you know your stuff, maybe your $0.02 would be much appreciated. Thanks.