Client: Ysleta del Sur Pueblo
Industry: Healthcare
Situation
Ysleta del Sur Pueblo (YDSP) is a federally recognized Native American tribe with 4,000+ members. The tribe provides many healthcare services through their own and affiliated health services, but services not directly available at YDSP run facilities may be billed through Purchased/Referred Care (PRC). PRC is a federally funded program and payment rates are based on Medicare payment methodology.
Challenge
When an individual received care through PRC, the YDSP PRC team mailed the individual’s medical claim to a third-party vendor. The vendor didn’t provide definitive timelines for pricing results, nor did they provide the methodology behind repricing the claim. The process was resource intensive and could lead to late payments, disputed rate amounts, or overpayment.
Solution
With Milliman’s guidance and support, the PRC team transitioned to using Milliman’s Medicare Reference Pricer. Now the team can instantly process PRC claims in house, and no longer rely on a third-party vendor. The Medicare Reference Pricer provides the detailed methodology behind repricing each claim, making it easier to resolve disputes and avoid overpaying for services. After an initial trial run, the YDSP PRC team transitioned to repricing all PRC claims in house, saving them valuable time and resources.