Oftentimes, when a member goes out-of-network most plans only pay benefits on a percentage of a hospital’s usual and customary charges. NBAS can assist payers in determining reasonable pricing on out-of-network claims through its line-by-line Reasonable & Customary Review. In addition to reviewing the claims for inflated pricing, NBAS also identifies coding errors, inconsistencies, unbundling and erroneous charges.
Unfortunately, there is no universal standard for determining usual and customary pricing for hospitals. Therefore, NBAS turns to numerous sources to benchmark reasonable and market-appropriate pricing analytics. Sources include historical claims data, national hospital pricing indexes, charge master data, industry publications and CMS data. NBAS’s software takes into account all available data and produces a fair and reasonable benchmark for each market segment (City, State & Zip).