Contract Methodology

Goal: We want to map each roid to a contract methodology. In this version, we rely on MRF representation of contract methodology in either the contract_methodology field of hospital MRF data or negotiated_type in payer MRF data.

"Contract methodology" may be one of:

• per diem
• fee schedule
• case rate
• percent of total billed charges

For some contract_methodology and negotiated_type values, we are not able to cleanly map them to one of the defined categories. For example, contract_methodology may be NULL or "other" and payer_negotiated may be "negotiated" or "derived".

We do not need to map every roid to a contract methodology, but a large fraction of our rates have payer_negotiated = 'negotiated' (over 30%). So we rely on whether the code is a surgery code to determine if it's a case rate or fee schedule.

Code:

First create a dictionary mapping each rate column to a contract methodology.

{% set methodology_mapping = {} %}
{% for col in hospital_raw_cols + payer_raw_cols + allowed_amounts + 
    hospital_transformation_cols + payer_transformation_cols + imputation_cols %}
    {% if 'case_rate' in col or 'base_rate' in col or 'cstm_negotiated_rate' in col %}
        {% set _ = methodology_mapping.update({col: "Case Rate"}) %}
    {% endif %}
    {% if 
        ('hospital_perc' in col) or 
        ('payer_' in col and 'perc_to_dol' in col) or 
        ('cstm_' in col and 'perc_to_dol' in col) or 
        ('rc_' in col and 'perc_to_dol' in col) 
    %}
        {% set _ = methodology_mapping.update({col: "Percent of Total Billed Charges"}) %}
    {% endif %}
    {% if 'fee_schedule' in col %}
        {% set _ = methodology_mapping.update({col: "Fee Schedule"}) %}
    {% endif %}
{% endfor %}

If a column is not in the mapping above, we use the following logic:

• If payer_negotiated or payer_derived and is_surg_code = True, then "Case Rate"
• If payer_negotiated or payer_derived and is_surg_code = False, then "Fee Schedule"
• If per_diem and `bill_type NOT IN ('Inpatient'), then "Case Rate"
• If per_diem and `bill_type IN ('Inpatient'), then "Per Diem"
• Else "Unknown"

{% for c in (rate_cols) %}
    {% if c in methodology_mapping %}
        '{{ methodology_mapping[c] }}'
    {% else %}
        CASE 
            WHEN {{ 'payer_negotiated' in c or 'payer_derived' in c }} AND is_surg_code = True
            THEN 'Case Rate'
            WHEN {{ 'payer_negotiated' in c or 'payer_derived' in c }} AND COALESCE(is_surg_code, False) = False
            THEN 'Fee Schedule'
            WHEN {{ 'per_diem' in c }} AND c.bill_type NOT IN ('Inpatient')
            THEN 'Case Rate'
            WHEN {{ 'per_diem' in c }} AND c.bill_type IN ('Inpatient')
            THEN 'Per Diem'
            ELSE 'Unknown'
        END
    {% endif %}
    {% if not loop.last %}, {% endif %}
{% endfor %}