Allowed Amount Variance Help

[vduffel99]

Hi All

I am completing the Median, 10th and 90th Percentile piece and have come across some interesting variances and not sure how to move forward. See examples below and in the WORD file. Any guidance is appreciated. Thank you.

Revenue Codes: for RC 25x and 27x ranges, the 835 leaves these generic and will bundle the allowed amounts into 1 bucket. When calculating the Median, 10th and 90th Percentile I compare these to the reimbursement amount and there are significant variances. Is that what CMS wants to see? Or if the negotiated amount is outside the percentiles, do we want to clear out the data and leave a note for a reason we are not including?

PT Example.docx

[Young-Rachel]

Hi vduffel99,

In general, hospitals should calculate the allowed amounts based off the unique code combinations for that item or service (i.e., row in CSV). For your specific example, would you be willing to send us an email at PriceTransparencyHospitalCharges@cms.hhs.gov with the headings in your example file expanded?

[rchinski12]

I have been checking each day for the answer to this. Is there a way after the specific example is provided by vduffel99 and reviewed that the direction provided by CMS is also shared?

[vduffel99]

Good Afternoon All - For those of you who were following this thread, I just received a response from CMS via email and wanted to share the response. My question was "In instances where multiple CDM lines will qualify to the same allowed amount value (for example revenue code 250), how should we document the percentiles ad claim count in the MRF? Below is the CMS response.

Thank you for emailing the Price Transparency Hospital Charges mailbox and seeking clarification on a component of the Hospital Price Transparency regulations.

Hospitals are required to encode their MRF with all applicable standard charge information that corresponds to each of the required data elements. We acknowledge that hospitals can contract using a base rate in dollars has been established but may then be modified depending on other factors like transfers or outliers), or a ‘‘percent of billed charges’’ schemes (in which the dollar amount varies from person to person based on what is charged). We ask that hospitals do not derive a standard charge dollar, but encode the information available in their fee schedules or contracts. We believe that section 2718(e) of the PHS Act directs the Secretary to tell hospitals how to display their standard charges, not how to establish them or that they must establish them (88 FR 82096).
Please note,

• If the payer-specific negotiated charge is based on a percentage that cannot be calculated as a standard charge dollar, for example, 87 % of total billed charges, the hospitals should encode 87 in the Payer-Specific Negotiated Charge: Percentage data element and then encode the allowed amount data elements.

• If the payer-specific negotiated charge is based on an algorithm, the hospital is required to (1) provide all necessary information available to the hospital, in a way that a reasonable MRF user can understand, in the Payer-Specific Negotiated Charge: Algorithm data element for the public to be able to derive a dollar amount, and (2) encode the allowed amount data elements. All necessary information available to the hospital would include, among other things, information in the hospital’s systems and payer contracts.

• If a hospital has encoded a payer-specific negotiated charge in the MRF as a dollar amount, and that dollar amount represents the full payer-specific negotiated charge that is not further modified by a percentage or algorithm, the hospital would not be required to encode the allowed amounts.

[Young-Rachel]

Thank you, vduffel99. To clarify for other readers, CMS was responding to the specific question of whether payer-specific negotiated charges could be outside the allowed amount ranges. If you have additional questions, please feel free to post a discussion question or email us directly at PriceTransparencyHospitalCharges@cms.hhs.gov.