Payer contract modeling against the Medicare baseline

Independent pricing tool. Not affiliated with, endorsed by, or operated by CMS or any government agency. Estimates are not a claims determination.

Claim

DRG and hospital

Claim details (optional)

Charges unlock percent-of-charges terms, stop-loss, the lesser-of cap and the Medicare outlier. Length of stay unlocks per diems.

Baseline carve-outs

Some contracts pay a percent of Medicare with add-ons left out. Unchecked items are removed from the baseline by the pricing engine.

Contracts against Medicare

Sample baseline for DRG 470 at Houston Methodist Hospital, saved from the pricing engine. Edit the payer terms below, or change the claim and press Set Medicare baseline.
Medicare baseline
Model the contracts against
Each scenario against the baseline modeled
    • Medicare baseline
    • Above baseline
    • Below baseline

    Payer scenarios

    Your contract terms. Payments are modeled in this browser from the baseline above; terms are saved in this browser only.

    Side by side

    modeled

    Baseline detail

    What is in the Medicare baseline

    How each term is modeled

    • % of Medicare: the baseline you chose × your percent.
    • Case rate: your flat amount per discharge.
    • % of billed charges: covered charges × your percent. Needs charges.
    • Per diem × LOS: your daily rate × the length of stay. Needs LOS.
    • Plus the Medicare outlier: adds the outlier inside the baseline to a case rate or per diem. A percent-of-Medicare term already scales it.
    • Stop-loss: adds your percent of the charges above your threshold.
    • Lesser of charges: caps the payment at covered charges.

    A model of the terms you enter, not a reading of any contract and not a claims determination. Contract language on carve-outs, outlier and stop-loss varies.

    Saved in this browser

    Only the payer terms (names, term types and rates) are kept, under this browser's storage. No claim details are saved, and the share link carries only the DRG, hospital, claim amounts and terms.

    Modeling a payer contract against Medicare

    Set the Medicare baseline for a DRG at a hospital, then add payer scenarios. Each scenario is shown as an expected payment, the dollar and percentage-point difference from the baseline and its percent of Medicare, so different contract structures can be compared on one footing.

    Questions

    Which baseline should I use?

    Original Medicare is the usual reference. Medicare Advantage out of network is useful for non-contracted claims.

    Are the scenario amounts from the API?

    The baseline is priced by the engine; the scenario math is applied in your browser and labelled as modeled.