https://cmswebpricer.com/news/ Medicare and Medicaid payment analysis for payers, TPAs and payment integrity teams: rate updates, worked examples and pricing rules, priced in the cmswebpricer.com engine. en-us Mon, 02 Nov 2026 12:00:00 GMT https://cmswebpricer.com/news/cy2027-physician-fee-schedule-proposed https://cmswebpricer.com/news/cy2027-physician-fee-schedule-proposed Mon, 02 Nov 2026 12:00:00 GMT cmswebpricer.com editorial team FY/CY updates 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. https://cmswebpricer.com/news/free-first-review-20-claim-lines https://cmswebpricer.com/news/free-first-review-20-claim-lines Mon, 02 Nov 2026 12:00:00 GMT cmswebpricer.com editorial team Payment integrity 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. https://cmswebpricer.com/news/san-antonio-same-wage-index-different-medicare-payment https://cmswebpricer.com/news/san-antonio-same-wage-index-different-medicare-payment Sat, 31 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team Inpatient DRG 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.” https://cmswebpricer.com/news/discount-is-not-a-price-who-wrote-the-starting-number https://cmswebpricer.com/news/discount-is-not-a-price-who-wrote-the-starting-number Thu, 22 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team Reference-based pricing 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. https://cmswebpricer.com/news/snf-claim-pricing-pdpm-per-diem https://cmswebpricer.com/news/snf-claim-pricing-pdpm-per-diem Tue, 20 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team How-to 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. https://cmswebpricer.com/news/fy2027-inpatient-rates-for-payers https://cmswebpricer.com/news/fy2027-inpatient-rates-for-payers Mon, 19 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team FY/CY updates 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. https://cmswebpricer.com/news/medicare-advantage-out-of-network-inpatient-payment https://cmswebpricer.com/news/medicare-advantage-out-of-network-inpatient-payment Mon, 19 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team Medicare Advantage 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. https://cmswebpricer.com/news/inpatient-cost-outlier-worked-example https://cmswebpricer.com/news/inpatient-cost-outlier-worked-example Mon, 19 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team Inpatient DRG 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. https://cmswebpricer.com/news/inpatient-transfer-per-diem-rule https://cmswebpricer.com/news/inpatient-transfer-per-diem-rule Mon, 19 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team Inpatient 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. https://cmswebpricer.com/news/reference-based-pricing-percent-of-medicare https://cmswebpricer.com/news/reference-based-pricing-percent-of-medicare Mon, 19 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team Reference-based pricing 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. https://cmswebpricer.com/news/drg-validation-single-mcc-risk https://cmswebpricer.com/news/drg-validation-single-mcc-risk Mon, 19 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team Payment integrity 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. https://cmswebpricer.com/news/date-of-service-fiscal-year-grouper-version https://cmswebpricer.com/news/date-of-service-fiscal-year-grouper-version Mon, 19 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team How-to 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. https://cmswebpricer.com/news/repricing-837i-claims-what-pricing-needs https://cmswebpricer.com/news/repricing-837i-claims-what-pricing-needs Mon, 19 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team How-to 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. https://cmswebpricer.com/news/hospital-outpatient-vs-asc-site-of-service https://cmswebpricer.com/news/hospital-outpatient-vs-asc-site-of-service Mon, 19 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team Outpatient 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. https://cmswebpricer.com/news/medicaid-apr-drg-ny-tx-co-compared https://cmswebpricer.com/news/medicaid-apr-drg-ny-tx-co-compared Mon, 19 Oct 2026 12:00:00 GMT cmswebpricer.com editorial team Medicaid 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.