Medicare Rate Variance Checking
Ingest official CMS Medicare fee schedule files (PFS, OPPS, ASC, Ambulance) and benchmark submitted medical bills against published rates. Phase 2 — bill-review integration — arriving soon.
Key benefits
- · Ingests CMS schedule files — Physician Fee Schedule, OPPS, ASC, Ambulance
- · Versioned rate schedules so historical bills reconcile against the right vintage
- · CSV / Excel / JSON export of ingested rate data
- · Phase 2 — per-line variance, threshold flagging, allowable-amount suggestion on expense-bill review (arriving)
Why benchmark against Medicare?
State victim-compensation programs routinely pay medical bills — ER visits, forensic exams, follow-up care. Without a benchmark, programs either trust the billed amount (expensive) or hand-negotiate each bill (slow). Medicare publishes fee schedules for nearly every procedure, keyed by CPT / HCPCS code and locality. Using Medicare as a benchmark is standard practice in public-program medical billing.
What VCPMS does — Phase 1 (shipped)
- Ingests CMS files. Physician Fee Schedule (PFS), OPPS, ASC, Ambulance — via tenant-scoped parsers.
- Stores as versioned schedules. Each ingested schedule is its own
MedicareRateSchedulerecord; historical bills reconcile against the schedule that was effective at service time. - Admin surface. Program admins upload, review, and activate schedules.
- Exports. CSV, Excel, JSON exporters for downstream analysis or verification.
- Feature-flagged per tenant.
App.MedicareRateVarianceturns the module on for programs that want it.
What arrives in Phase 2
- Per-line variance. On each line of a submitted medical bill, VCPMS computes the billed amount vs. the published Medicare rate for that CPT / HCPCS code and locality.
- Threshold flagging. Configurable threshold (e.g., “flag bills above 150% of Medicare”) surfaces outliers to the reviewer.
- Allowable-amount suggestion. Based on Medicare rate plus program policy, VCPMS suggests an allowable amount — a default reviewers can accept or override.
- ExpenseBill review integration. The variance check lives directly on the bill-review screen.
Why “arriving” instead of “shipped”
Phase 1 — schedule ingestion and admin — is in production. Phase 2 — bill-review integration — is in active development. Marketing copy distinguishes so procurement conversations stay honest.