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If you told Spencer-of-ten-years-ago that I’d be building a Medicare Pricer in 2025, my first thought might have been, “How am I here again?!"
Ten years ago, I was deep in revenue cycle consulting rebuilding pricing engines every quarter, deciphering CMS rules, and helping hospitals catch underpayments that slipped through the cracks. I’ve experienced firsthand how seemingly minor barriers in Medicare pricing can end up costing organizations thousands of hours and millions of dollars. The effects compound quickly: misaligned benchmarks, delayed payments, and flawed forecasts.
Fast forward to today, I have two beautiful children and the revenue cycle industry still can’t calculate reimbursement without heavy, time-intensive engineering resources. The tools are there, technically, but the path from CMS logic to usable pricing is anything but straightforward.
Thankfully, as a Product Manager at Turquoise, I finally had the chance to solve this problem at the source.
Here it is: our just launched, free Medicare Pricer—now let me tell you how it’s different.
Inaccessible Medicare pricing plagues more than just hospitals
In 2023, Medicare paid hospitals approximately $436 billion for Part A and Part B benefits. Many of my former clients couldn't accurately verify the more complex payments (looking at you, OPPS). And without flexible repricing tools, they struggled to diagnose revenue shortfalls or successfully file appeals. Potential underpayments just got absorbed.
Staffing shortages only made things harder. I watched lean teams juggle manual pricing processes that used to require dedicated specialists like me. In smaller or rural hospitals, hiring that expertise wasn’t even an option.
But this isn’t just a hospital problem. Fast, reliable Medicare pricing touches nearly every corner of the industry:
- Consultants need to flag underpayments and build defensible benchmarks
- Payers use Medicare prices when comparing contract rates to Medicare baselines
- Strategic planners use it to model pricing scenarios
- Revenue cycle teams monitor performance so they know what they’re going to get paid
Medicare pricing isn’t a new challenge, but it remains surprisingly unsolved.
The industry's predictable but broken evolution
There are currently a few different ways one can attempt to price medicare claims:
Manual Builds
Many teams still download CMS files directly and implement the logic themselves. This was my world for years. It allows for control but requires technical skill and takes an enormous amount of time every quarter when the logic is updated.
Command-Line Interfaces
CMS offered downloadable PC programs with MS-DOS-style, text-based menus for entering claim details. Accurate? Yes. But imagine pricing 5,000 claims with software that looks like it was built before the internet. Not ideal.
Web-Based Pricers
CMS created browser-based pricing interfaces. These improved access but still only work on one claim at a time.
Source Code Publication
In recent years, CMS began releasing Java code for Medicare pricing systems. It’s a step forward, and fairly progressive for healthcare standards, but many provider organizations don’t have the engineering bandwidth to implement and maintain these tools internally.
These solutions fix parts of the problem, but not the whole thing. So we keep seeing the same logic rebuilt over and over, by consultants, vendors, hospital teams, all working in silos, resulting in massive duplication of effort across the industry.
When the opportunity to build a Medicare Pricer to support our own products came up, we knew we wanted to do things differently. If we could drastically improve and simplify this process for ourselves, why not make it something any one could use?
We designed the Medicare Pricer to make claim pricing easier for anyone
It starts with a simple file upload. No custom setup. No specialized training. No engineering support.
Our Pricer supports bulk pricing, beginning with inpatient (IPPS) and outpatient (OPPS) claims. It runs on the same infrastructure we use internally at Turquoise to support our modeling, benchmarking, and analytics products, so it’s already scaled for high volume and built to reflect CMS’ quarterly logic updates.
Upload your file, hit “run pricing,” then download a CSV with Medicare prices
If you were me ten years ago or you are right now, I think you’ll find this actually does everything you need it to. Once you sign up, you’ll be able to price 10k claims a month for free.
A few highly technical fun facts about our Pricer to delight the rev cycle nerds among us:
- It supports eight Medicare pricers (professional and ASC claims are following close behind!)
- It handles adjustments for NCCI, MUE, 340B, multi-procedure and much more to get you the most accurate prices
- We consolidated dozens of source data sets posted by CMS into our reference data tables, accumulated historically each quarter since 2021
- It automatically scales up based on the amount of claims submitted. So we can handle files big and small like it’s nothin’
Ah, efficiency.
Another inefficiency bites the dust
We know this tool won’t fix every inefficiency in healthcare, but we’re confident it will solve a particularly sharp thorn in revenue cycle's side. The system is complex, and no single product can unwind that. But pricing logic doesn’t need to stay one of the painful parts.
I think about me from ten years ago, stuck sifting through Excel files, decoding CMS documentation, and rebuilding pricing systems from scratch. This would’ve changed everything. And that’s exactly the point. If this helps someone avoid a rebuild, flag an underpayment, or model payments faster, then it’s doing what it was built to do.
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