Strategic Pricing and Reimbursement Reviews/Modeling

    Strategic Pricing and Reimbursement Reviews/Modeling

    Health care providers are facing increasing pressure from insurers and patients to provide transparency and comparability in service pricing. The growth in retail medicine and the out-of-pocket costs paid by patients are forcing health care organizations to develop defensible market-based pricing for services. Wipfli has the tools and processes to help organizations prepare for this new reality.

    Areas of Expertise 

    • Professional (CMS 1500) and technical (UB-04) claims and related data
    • Hospital revenue codes, CPT, and HCPCS coding
    • Ambulatory payment system reimbursement (APCs)
    • DRG-based reimbursement models
    • RBRVS, provider-based, and other reimbursement models for physician services
    • Bundled/unbundled services
    • Access to state-specific and federal claims data for price comparability at the CPT level 

    Types of Services 

    • Strategic pricing model for hospital services using competitive data:
      • Modeling changes in gross revenue and reimbursement by type of service based on competitor analysis
      • Developing tools and templates to support pricing of new services
      • Modeling pricing based on Medicare reimbursement levels
      • Ensuring that pricing for same/similar services is aligned within multi-hospital systems
    • Strategic pricing model for physician services using RBRVS, reimbursement, and competitive data:
      • Understanding sensitivity to existing fees, market pressures, and patient perception
      • Focusing on code categories and their specific issues (E/M, surgery, medicine, radiology)
      • Modeling changes in net revenue by code, by clinic, or by department
      • Developing pricing template to support pricing of new services

    Contact: Jane Jerzak or Vicki Mueller