PRICERActive™ Reimbursement Components

Administration and payment of Medicare claims is the responsibility of the Centers For Medicare and Medicaid Services, a division of the U.S. Dept of Health and Human Services. Inpatient hospital stays are paid under the guidelines of the Prospective Payment System (PPS). The payment methodology under PPS is a very complex one. It utilizes the weighting factors from the Diagnosis Related Group (DRG) that is calculated from the patient’s hospital discharge data. The Medicare payment formula then uses national and regional payment rates, hospital-specific geographic and cost factors to compute a basic payment amount. Additional payments are made for the hospital capital-related costs and high cost cases are eligible for additional cost outlier payments.

PRICERActive™ Components duplicate the calculations used by Medicare for inpatient hospital claim payment and provide a convenient way to add complex Medicare reimbursement logic to your systems or applications. PRICERActive™ uses the same formulas and Medicare hospital-specific data that the Medicare contractors use to calculate claim payments. By simply referencing the PRICERActive™ component within your application, setting the input property values, and executing the PricerCalc method you can calculate an estimated Medicare payment for any hospital in the U.S. including any cost outlier amount or the cost outlier threshold for the case.

PRICERActive™ Reimbursement Components are the ideal solution for claims processing applications, data warehousing and data analysis, claim review, compliance auditing, repricing applications and more.

Availability:

There are two types of PRICERActive™ DLLs to match your system architecture:

• Desktop versions of PRICERActive™ DLLs utilize Microsoft Access databases for fast and efficient in-line processing.
• PRICERActive Enterprise™ DLLs are available in .Net format and utilize Microsoft SQL Server data components for high-performance in large-scale enterprise and web-based applications.

PRICERActive™ DLLs are available covering different time periods to meet your data requirements:

• We have a 2-Year PRICERActive™ DLL that will calculate inpatient reimbursement amounts for two fiscal years of Medicare specifications and a 5-Year PRICERActive™ DLL that will calculate inpatient reimbursement amounts for five fiscal years of Medicare specifications.

Features include:

• Hospital-specific Medicare claim reimbursement calculation, with an option to calculate Medicare HMO reimbursement
• Calculates all components of a Medicare PPS payment:
• Federal Specific Portion
• Hospital Specific Portion
• Capital-related Portion
• Cost Outlier Portion
• Indirect Medical Education Adjustment
• Disproportionate Share Adjustment
• New technology add-on
• Low-volume add-on
• Hospital readmission adjustment
• Value-based purchasing adjustment
• Uncompensated care adjustment
• HAC reduction

Compatible with the leading Windows development environments including:

• Microsoft Visual Studio
• Microsoft .Net Core (.Net, 6, 7, 8)
• Microsoft .Net Framework 4.6.2+
• Microsoft SQL Server

Scalable:

PRICERActive™ Reimbursement Components come in versions suitable for desktop applications as well as Enterprise Versions designed for high-performance large-scale applications that utilize Microsoft SQL Server. Send e-mail to salesinfo@microdynmed.com or call for more information and pricing.

Licensing:

PRICERActive™ components are licensed based upon usage.

For a single site installation, like a health plan, hospital, or university, the PRICERActive™ components are licensed for internal use based on the size of the installation.

For a Software Developer including a PRICERActive™ component in a software package for distribution to an end user, a distribution agreement is required. Terms: an initial license fee and a per-site fee for each PRICERActive™ Component.

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