Real World Rates
One-liner: Rates that reflect services that are expected to fluctuate between encounters, such as % of charges, but all components of the formula used to derive the rate come directly from reported data.
These rates are the typical per diem, percent of charge, and other variable payment models common in contracts. While these rates are indeed the best possible rates to show for such provisions, their whole $ amounts are expected to fluctuate from claim-to-claim and thus require a slight discount in "defensibility" compared to Posted Rates. Since all of the components of the calcualtion come directly from the posted data, there would not be a more accurate way to arrive at the rate.
Examples would be:
- 90% of charges and average charge of $50,000 are both reported in the MRF
- $5,000 per diem and average length of stay of 2 days are both reported in the MRF
Rate Types​
Raw Real World Rates​
These are unprocessed rates that reflect encounter-level variability, sourced directly from reported data.
Hospital MRF Reported Allowed Amounts​
| Rate Type | Source | Contract Methodology* | Description |
|---|---|---|---|
raw: hospital_per_diem_allowed_amount | hospital | per diem | Hospital per diem rates from allowed amounts |
raw: hospital_case_rate_allowed_amount | hospital | case rate | Hospital case rates from allowed amounts |
raw: hospital_fee_schedule_allowed_amount | hospital | fee schedule | Hospital fee schedule from allowed amounts |
raw: hospital_null_methodology_allowed_amount | hospital | null | Hospital null methodology from allowed amounts |
raw: hospital_other_allowed_amount | hospital | other | Hospital other methodology from allowed amounts |
raw: hospital_percent_of_total_billed_charges_allowed_amount | hospital | percent of charge | Hospital percentage rates from allowed amounts |
raw: hospital_per_diem_untransformed_allowed_amount | hospital | per diem | Untransformed hospital per diem from allowed amounts |
raw: hospital_case_rate_untransformed_allowed_amount | hospital | case rate | Untransformed hospital case rates from allowed amounts |
raw: hospital_fee_schedule_untransformed_allowed_amount | hospital | fee schedule | Untransformed hospital fee schedule from allowed amounts |
raw: hospital_null_methodology_untransformed_allowed_amount | hospital | null | Untransformed hospital null methodology from allowed amounts |
raw: hospital_other_untransformed_allowed_amount | hospital | other | Untransformed hospital other methodology from allowed amounts |
raw: hospital_percent_of_total_billed_charges_untransformed_allowed_amount | hospital | percent of charge | Untransformed hospital percentage rates from allowed amounts |
Claims Raw Rates​
| Rate Type | Source | Contract Methodology* | Description |
|---|---|---|---|
raw: komodo_allowed_amount_line_item | claims | allowed amount | Komodo allowed amounts at line item level |
raw: komodo_allowed_amount_claim | claims | allowed amount | Komodo allowed amounts at claim level |
*as reported in MRF file
Transformed Real World Rates​
These are rates processed through standardization where all components come from reported data.
Per Diem Transformations​
We multiply the Per Diem rate reported in the MRF by the medicare GLOS (geometric mean length of stay).
| Rate Type | Source | Contract Methodology* | Description |
|---|---|---|---|
transform: hosp_per_diem_mult_glos | hospital | per diem | Hospital per diem multiplied by geometric length of stay |
transform: hosp_gc_hosp_per_diem_perc_to_dol_mult_glos | hospital | per diem | Hospital per diem percentage converted using hospital gross charges and multiplied by GLOS |
transform: payer_per_diem_mult_glos | payer | per diem | Payer per diem multiplied by geometric length of stay |
Percent of Charge Transformations​
We multiply Percent-of-Charge rates reported in MRF files by gross charges that were also directly reported by the hospital in MRF files.
| Rate Type | Source | Contract Methodology* | Gross Charge Source | Description |
|---|---|---|---|---|
transform: hospital_case_rate_gc_hosp_perc_to_dol | hospital | case rate | hospital MRF | Hospital case rate percentage converted using hospital gross charges |
transform: hospital_fee_schedule_gc_hosp_perc_to_dol | hospital | fee schedule | hospital MRF | Hospital fee schedule percentage converted using hospital gross charges |
transform: hospital_null_methodology_gc_hosp_perc_to_dol | hospital | null | hospital MRF | Hospital null methodology percentage converted using hospital gross charges |
transform: hospital_other_gc_hosp_perc_to_dol | hospital | other | hospital MRF | Hospital other methodology percentage converted using hospital gross charges |
transform: hospital_perc_of_total_billed_charges_gc_hosp_perc_to_dol | hospital | percent of charge | hospital MRF | Hospital percentage of total billed charges converted using hospital gross charges |
transform: payer_gc_hosp_perc_to_dol | payer | percent of charge | hospital MRF | Payer percentage converted using hospital gross charges |
Drug Dosage Standardized Transformations​
For some drug rates from hospital data, we need to standardize the dosage.
| Rate Type | Source | Contract Methodology* | Gross Charge Source | Description |
|---|---|---|---|---|
transform: drug_dosage_std_case_rate_dollar | hospital | case rate | hospital MRF | Drug dosage standardized case rate in dollars |
transform: drug_dosage_std_percent_of_total_billed_charges_dollar | hospital | percent of charge | hospital MRF | Drug dosage standardized percentage of total billed charges in dollars |
transform: drug_dosage_std_fee_schedule_dollar | hospital | fee schedule | hospital MRF | Drug dosage standardized fee schedule in dollars |
transform: drug_dosage_std_other_dollar | hospital | other | hospital MRF | Drug dosage standardized other methodology in dollars |
transform: drug_dosage_std_null_methodology_dollar | hospital | null | hospital MRF | Drug dosage standardized null methodology in dollars |
transform: drug_dosage_std_case_rate_perc_to_dol | hospital | case rate | hospital MRF | Drug dosage standardized case rate percentage converted to dollars |
transform: drug_dosage_std_percent_of_total_billed_charges_perc_to_dol | hospital | percent of charge | hospital MRF | Drug dosage standardized percentage of total billed charges converted to dollars |
transform: drug_dosage_std_fee_schedule_perc_to_dol | hospital | fee schedule | hospital MRF | Drug dosage standardized fee schedule percentage converted to dollars |
transform: drug_dosage_std_other_perc_to_dol | hospital | other | hospital MRF | Drug dosage standardized other methodology percentage converted to dollars |
transform: drug_dosage_std_null_methodology_perc_to_dol | hospital | null | hospital MRF | Drug dosage standardized null methodology percentage converted to dollars |
Canonical Rate Type Format​
Real world rates use the canonical rate type format: {category}: {rate_source} where:
- Category indicates the processing level (raw, transform)
- Rate Source identifies the specific rate column used
Common Abbreviations​
- gc: Gross Charge
- hosp: Hospital
- perc_to_dol: Percentage converted to dollar amount
- mult_glos: Multiplied by Geometric Length of Stay
- std: Standardized