Monroe County Hospital utilizes CPSI as its third-party information system for patient billing, which houses its payer contract information. Monroe County is using CPSI’s standard output as the content for most of the facility-specific machine-readable standard charges files.

Due to limitations in presenting complicated and differing contracted rate methodologies in a standardized way, the contracted rate (i.e., payer-specific negotiated charges) in the machine-readable files will not always reflect the contracted rate that applies in an individual patient’s case. As described below, there are variables that exist by patient and/or health insurance plan that must be taken into account to arrive at contracted rates applicable for specific items and services.

If there is a discrepancy between a payer-specific negotiated charge listed in the machine-readable file(s) and the contracted rate applicable to a specific patient claim, the terms of the payer contract will control, so the machine-readable file(s) may be of limited benefit to our patients. We recommend Monroe County Hospital patients use our Price Estimation tool for personalized cost estimates for hospital services.

Examples of potential contracted rate differences include but are not limited to the following:

Payer contracts based on DRG reimbursement

Some payers base rates on diagnosis related group (DRG) reimbursement with additional payment terms. In some cases, a payer-specific negotiated charge provided in the machine-readable file(s) may not always be applicable to an individual case due to differences in negotiated rate methodology that depend on the mix of items and services on a claim. For example, differences in length of stay and calculation methods may result in a payment rate for some patient claims that vary from the payer-specific negotiated charges reflected in the machine-readable file(s).

Per diem rates

Per diem rates in the machine-readable file(s) were calculated based on the length of stay for the median account. Rates in an individual case will depend on the patient’s actual length of stay.

Payers with negotiated charges based on age category

Some payers have negotiated charges that are based on age category (for example, adult and pediatric). Monroe County Hospital calculates the contracted rate in the machine-readable file(s) based on a single median account. Rates in the machine-readable file(s) may be calculated based on an adult or a pediatric case.

Medicare Advantage health insurance plans and other payers using Medicare methodology

For Medicare Advantage health insurance plans and payer rates based on Medicare methodology, contracted rates in the machine-readable file(s) may not reflect the rate applicable to every individual case, because the methodology calculates the contracted rate without factoring in service location, provider group, rate hierarchy and other pricing calculations applicable to Medicare payment methodologies.

Medicare rates are typically updated annually on October 1, for inpatient rate updates, and January 1, for outpatient rate updates. Medicare may make retrospective rate changes that are not reflected in the machine-readable file(s) because the file was created before Monroe County Hospital received notification of the rate change.

Please consult publicly available Medicare rates for additional rate information.

Payers with varying rate terms

Some payer contracts have varying rate methodologies. In some cases, a payer-specific negotiated charge provided in the machine-readable file(s) may not be applicable to an individual case due to differences in negotiated rate methodology that depend on the mix of services on a claim. Differences in service type and location could affect the rates that apply in an individual case.

Physician and advanced practice provider professional services

When multiple services are billed during a single visit to a physician or advanced practice provider, contracted rates for the secondary and subsequent services could be reduced, depending on the contract terms/payer policies. Contracted rates in the machine-readable file are for physician services. The contracted rates are based on a single service and do not contain any discounting for multiple services. Contracted rates will also not reflect any discounts from physician rates which may be applicable to services performed by advanced practice providers, such as physician assistants and nurse practitioners.

Out-of-network insured patients

Discounted cash rates are reflective of patients without insurance coverage, and do not apply to patients with health insurance plans for which the hospital is out-of-network.

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