News and analysis
Medicare and Medicaid payment, explained for payers
Rate updates, worked examples and pricing rules for payer, TPA and payment integrity teams. Every worked example is priced in the cmswebpricer.com engine, with the rate year and the date it was run.
Featured · FY/CY updates
FY2027 inpatient rates: what changed on October 1 for payers pricing DRG claims
A 2.3% update, an outlier fixed-loss amount up 22%, MS-DRG version 44 and a correction published two days before the start date. With $520,000 in charges, the same sepsis stay pays $10,300.23 less on October 1 than on September 30 because its outlier shrinks; without an outlier it would be paid $831.47 more.
Read the analysis: FY2027 inpatient rates: what changed on October 1All articles
Category
Tags (15)
15 articles
- FY/CY updates
CY2027 physician fees, proposed: a 1.68% lower conversion factor and a same-day visit cut
The proposed CY2027 conversion factor is $32.8409, down 1.68%. A proposed rule would pay a same-day visit billed with modifier 25 at 50% next to a global-period procedure. Here is what it does to a real claim.
- Payment integrity
Free first review: 20 claim lines, priced step by step
Send up to 20 claim lines with names, member IDs and dates of birth removed. Each line comes back priced, with every step shown, next to what was allowed and paid, and flagged over or under. Free, and back within 5 business days.
- Inpatient DRG
Same city, same wage index: why Medicare pays five San Antonio hospitals $15,041 to $41,619 for one sepsis stay
Five hospitals from four systems (Methodist, Baptist, Christus Santa Rosa and University Health) share one wage index and one operating base: $13,155.69 for a five-day sepsis stay. The totals run 2.8 to 1. Here is every step, and what it means for the next contract that says “percent of Medicare.”
- Reference-based pricing
A discount is not a price: who wrote the number it starts from?
A generic guarantee at 85.5% off AWP, a hospital contract at 50% off charges, an out-of-network allowance at a percent of a database. In each one the discount is real and the base belongs to someone else. The 2024 Medicare file shows what that means for one sepsis admission at 13 Houston hospitals.
- How-to
Pricing a SNF claim: the PDPM per diem, interim bills and consolidated billing
A skilled nursing facility’s 21x claim is paid a PDPM per diem from the HIPPS code and covered days on each revenue code 0022 line. Therapy, drugs and labs ride along at no extra pay, the day of the stay changes the rate, and a 14-day stay across October 1 is priced at two years’ rates. Worked through one claim.
- FY/CY updates
FY2027 inpatient rates: what changed on October 1 for payers pricing DRG claims
A 2.3% update, an outlier fixed-loss amount up 22%, MS-DRG version 44 and a correction published two days before the start date. With $520,000 in charges, the same sepsis stay pays $10,300.23 less on October 1 than on September 30 because its outlier shrinks; without an outlier it would be paid $831.47 more.
- Medicare Advantage
Why a Medicare Advantage plan owes an out-of-network hospital less than Original Medicare
Medicare pays teaching hospitals the operating IME and the per-diem pass-through for Medicare Advantage patients itself. At NewYork-Presbyterian that is 27.0% of a sepsis stay; at a non-teaching hospital it is almost nothing.
- Inpatient DRG
Inpatient cost outliers, worked through one sample claim
Charges become cost, cost is compared with a threshold, and Medicare pays 80% of the excess. A $520,000 sepsis stay earns an $8,368.59 outlier in FY2027, and every extra $100,000 of charges adds $15,280.00.
- Inpatient DRG
Transfers and the per-diem rule: when a short stay pays less than the full DRG
A two-day sepsis stay that ends in a transfer to another hospital is paid three per diems: 62.5% of the full DRG amount. When the rule applies, when it does not, and which discharge codes trigger it.
- Reference-based pricing
Reference-based pricing at a percent of Medicare: how a TPA computes the number
Price the claim the way Medicare would, decide what “Medicare” includes, apply the multiple, then test it against the bill. A worked MS-DRG 871 example at 150% and 140%, with and without an outlier.
- Payment integrity
DRG validation and the single-MCC claim: when one code moves the payment
A heart failure stay groups to MS-DRG 291, 292 or 293 depending on one malnutrition code. At one New York hospital that is a $9,387.98 swing, and it is the pattern federal auditors have tested.
- How-to
Which year’s rates apply? Discharge dates, the October 1 line and grouper versions
Inpatient claims are coded, grouped and priced as of the discharge date. Outpatient lines price on the quarterly table for their own service dates and split at December 31. One sepsis stay, discharged September 30 or October 1.
- How-to
Repricing an 837I: what the claim file carries and what pricing still needs
The 837I gives you codes, dates, discharge status and charges. Pricing also needs the hospital’s CCN, the payment year and the plan’s own rules. A field-by-field checklist with a sample claim you can parse live.
- Outpatient
Hospital outpatient vs ASC: the site-of-service gap in dollars for four procedures
At CY2026 Medicare rates the same procedure pays a hospital outpatient department 1.9 to 2.1 times the ambulatory surgical center rate. What drives the gap, and what a payer should check before steering.
- Medicaid
Medicaid APR-DRG in New York, Texas and Colorado: one septicemia stay, three prices
APR-DRG 720 at severity 3 pays $22,417.87 at Mount Sinai, $6,873.08 at Memorial Hermann and $11,183.98 at Denver Health. The grouper family is shared; the payment formulas are not.
No article matches those filters. Try another word, or clear the filters.