Medicare Like Rates
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 ruled that Tribal Members obtaining healthcare at Medicare-participating hospitals pay no more than Medicare designated prices for their healthcare services. Hospital facilities charge far more than the Medicare Like Rates (MLR), so it is in the Tribal Enterprise’s best interest to make sure that its benefit plan is utilizing MLR when possible.
Since these regulations became effective on July 5, 2007, it is estimated that few TSIPs are taking full advantage of the relatively new regulations mostly due to the specialized administration required to properly process these complex claims.
At TribalCARE, we are not only proficient in processing these claims, we have extensive Medicare repricing experience and currently process claims for several Tribal entities. TribalCARE is uniquely qualified to properly identify, reprice and process claims regardless if the claim is from a Tribal or non-Tribal member and deliver those savings back to the Tribal organization.
After a claim is submitted to TribalCARE, and the member’s eligibility and Tribal affiliation is verified, we coordinate the process to reprice the claim at the lower MLR. Contracted providers are not required to bill at MLR. However, they are required to accept payment at MLR if the facility is a Medicare participating hospital.
With TribalCARE, our procedures ensure that:
coverage is verified
proper approvals and authorizations are obtained
federal and Tribal dollars are maximized
claims are repriced at Medicare Like Rates (MLR) when applicable
claims from Tribal Members and non-Tribal Members are processed
appropriate claims are paid quickly and accurately to each provider