Medicare Like Rates
Under the Medicare Modernization Act, Indian Tribal Entities are eligible to take advantage of Medicare
Like Rate Pricing or the Contracted rate for all hospital and hospital owned entities. Health West prices
claims for all tribal members and provides the best contracted rates for Tribal entities in order for them to
take advantage of the best pricing available. We separate the tribal member claims from the other
members and provide the appropriate pricing levels.
We have been providing Indian Tribal Enterprises and Tribes
with custom provider networks and MLR pricing since 2009.
Advantages of using Health West
Every year there are changes in the Medicare Pricing Methodology and we find that most Tribal Entities are over paying on their MLR claims because other companies do not stay abreast of the changes and update their systems in a timely manner. Based on actual audits we have found that 1 out of every 2 claims were paid incorrectly. The average savings for Tribes using Health West was an additional 32.9%. Health West will also perform the collection and recovery for the plan for an additional fee.
We develop custom networks and establish discounts for non - MLR services such as physicians, labs and ancillary care in order to provide best pricing for non-hospital providers. We customize and supplement the Medicare Like Rate pricing with your chosen providers in order to assist with directing care into your higher quality and lower cost providers.
We provide MLR pricing services based on a % of savings, a per claim cost and / or a per employee per month cost and allow the tribal entity the ability choose based on their needs.
The final ruling for Tribal entities Medicare Like Rates is found in “Section 506 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003—Limitation on Charges for services furnished by Medicare Participating Inpatient Hospitals to Individuals Eligible for Care Purchased by Indian Health Programs”
(72 FR 30706), includes all “IHS-Funded” health care programs whether operated by the IHS, Tribes, Tribal Organizations, or Urban Indian Organizations.”
The payment methodology applies to all levels of care furnished by a Medicare-participating hospital whether provided as inpatient, outpatient, skilled nursing facility care as other services of a department, subunit, distinct part or other component of a hospital. All hospitals that participate in Medicare, including any hospital clinics located off-site and Critical Access Hospitals. "Hospitals" may include:
The Medicare Like Rates regulations enable Indian health programs to use the resulting savings to increase services to their beneficiaries.
Phone - (888) 316-1933
Fax - (888) 316-8572