Enhanced Rates
One-liner: Rates that reflect a provision where the rate-driver is sourced directly from reported data, but the rest of the calculation is taken from benchmark data.
These rates reflect such cases where the Provision is reported in the MRF, but the claim-level benchmark is not. For example, the MRF reports 90% of charges but does not report the average charge amount for the service. In order to complete the calculation, Turquoise must grab average charges from other sources (e.g. Komodo data) to arrive at the rate.
Rate Types​
Percent of Charge​
We multiply Percent-of-Charge rates reported in MRF files by gross charges that were not directly reported by the hospital in an MRF file, but estimated. The "gross charge source" column below indicates how the gross charge was estimated.
For all geographically derived estimates (e.g., CBSA-average, State-average), we apply a CCR adjustment: using Medicare data on hospitals’ average charges per discharge, we calculate each hospital’s relativity to the CBSA average. This relativity factor is then used to scale the CBSA-average gross charge for a given code, allowing us to estimate a provider-specific gross charge.
| rate type name | source | contract methodology* | gross charge source |
|---|---|---|---|
| transform: hosp_gc_komodo_per_diem_perc_to_dol_mult_glos | hospital | per diem | komodo npi |
| transform: hospital_case_rate_gc_komodo_perc_to_dol | hospital | case rate | komodo npi |
| transform: hospital_fee_schedule_gc_komodo_perc_to_dol | hospital | fee schedule | komodo npi |
| transform: hospital_null_methodology_gc_komodo_perc_to_dol | hospital | null | komodo npi |
| transform: hospital_other_gc_komodo_perc_to_dol | hospital | other | komodo npi |
| transform: hospital_perc_of_total_billed_charges_gc_komodo_perc_to_dol | hospital | percent of charge | komodo npi |
| transform: payer_gc_komodo_perc_to_dol | payer | percent of charge | komodo npi |
| transform: hosp_gc_hosp_cbsa_per_diem_perc_to_dol_mult_glos | hospital | per diem | hospital MRF CBSA |
| transform: hosp_gc_komodo_cbsa_per_diem_perc_to_dol_mult_glos | hospital | per diem | komodo CBSA |
| transform: hospital_case_rate_gc_hosp_cbsa_perc_to_dol | hospital | case rate | hospital MRF CBSA |
| transform: hospital_case_rate_gc_komodo_cbsa_perc_to_dol | hospital | case rate | komodo CBSA |
| transform: hospital_fee_schedule_gc_hosp_cbsa_perc_to_dol | hospital | fee schedule | hospital MRF CBSA |
| transform: hospital_fee_schedule_gc_komodo_cbsa_perc_to_dol | hospital | fee schedule | komodo CBSA |
| transform: hospital_null_methodology_gc_hosp_cbsa_perc_to_dol | hospital | null | hospital MRF CBSA |
| transform: hospital_null_methodology_gc_komodo_cbsa_perc_to_dol | hospital | null | komodo CBSA |
| transform: hospital_other_gc_hosp_cbsa_perc_to_dol | hospital | other | hospital MRF CBSA |
| transform: hospital_other_gc_komodo_cbsa_perc_to_dol | hospital | other | komodo CBSA |
| transform: hospital_perc_of_total_billed_charges_gc_hosp_cbsa_perc_to_dol | hospital | percent of charge | hospital MRF CBSA |
| transform: hospital_perc_of_total_billed_charges_gc_komodo_cbsa_perc_to_dol | hospital | percent of charge | komodo CBSA |
| transform: payer_gc_hosp_cbsa_perc_to_dol | payer | percent of charge | hospital MRF CBSA |
| transform: payer_gc_komodo_cbsa_perc_to_dol | payer | percent of charge | komodo CBSA |
| transform: hosp_gc_hosp_state_per_diem_perc_to_dol_mult_glos | hospital | per diem | hospital MRF state |
| transform: hosp_gc_komodo_state_per_diem_perc_to_dol_mult_glos | hospital | per diem | komodo state |
| transform: hospital_case_rate_gc_hosp_state_perc_to_dol | hospital | case rate | hospital MRF state |
| transform: hospital_case_rate_gc_komodo_state_perc_to_dol | hospital | case rate | komodo state |
| transform: hospital_fee_schedule_gc_hosp_state_perc_to_dol | hospital | fee schedule | hospital MRF state |
| transform: hospital_fee_schedule_gc_komodo_state_perc_to_dol | hospital | fee schedule | komodo state |
| transform: hospital_null_methodology_gc_hosp_state_perc_to_dol | hospital | null | hospital MRF state |
| transform: hospital_null_methodology_gc_komodo_state_perc_to_dol | hospital | null | komodo state |
| transform: hospital_other_gc_hosp_state_perc_to_dol | hospital | other | hospital MRF state |
| transform: hospital_other_gc_komodo_state_perc_to_dol | hospital | other | komodo state |
| transform: hospital_perc_of_total_billed_charges_gc_hosp_state_perc_to_dol | hospital | percent of charge | hospital MRF state |
| transform: hospital_perc_of_total_billed_charges_gc_komodo_state_perc_to_dol | hospital | percent of charge | komodo state |
| transform: payer_gc_hosp_state_perc_to_dol | payer | percent of charge | hospital MRF state |
| transform: payer_gc_komodo_state_perc_to_dol | payer | percent of charge | komodo state |
*as reported in MRF file
Inferred Provision​
For more details on tier computations, click here
| rate type name | provision | contract methodology | gross charge source |
|---|---|---|---|
| impute: msdrg_base_rate_mult_cms_weight | MS-DRG base rate | fee schedule | |
| impute: msdrg_mrf_base_rate_mult_cms_weight* | MS-DRG base rate | fee schedule | |
| impute: rc_family_gc_hosp_perc_to_dol | RC Family | percent of charge | hospital MRF |
| impute: rc_family_gc_komodo_perc_to_dol | RC Family | percent of charge | komodo npi |
| impute: rc_family_gc_komodo_cbsa_perc_to_dol | RC Family | percent of charge | komodo CBSA |
| impute: rc_family_gc_hosp_cbsa_perc_to_dol | RC Family | percent of charge | hospital MRF CBSA |
| impute: rc_family_gc_hosp_state_perc_to_dol | RC Family | percent of charge | hospital MRF state |
| impute: rc_family_gc_komodo_state_perc_to_dol | RC Family | percent of charge | komodo state |
| impute: rc_family_per_diem_mult_glos | RC Family | per diem | |
| impute: msdrg_gc_hosp_base_perc_to_dol | MS-DRG base percentage | percent of charge | hospital MRF |
| impute: msdrg_gc_komodo_base_perc_to_dol | MS-DRG base percentage | percent of charge | komodo npi |
| impute: msdrg_gc_hosp_cbsa_base_perc_to_dol | MS-DRG base percentage | percent of charge | hospital MRF CBSA |
| impute: msdrg_gc_komodo_cbsa_base_perc_to_dol | MS-DRG base percentage | percent of charge | komodo CBSA |
| impute: msdrg_gc_hosp_state_base_perc_to_dol | MS-DRG base percentage | percent of charge | hospital MRF state |
| impute: msdrg_gc_komodo_state_base_perc_to_dol | MS-DRG base percentage | percent of charge | komodo state |
| impute: rc_global_gc_hosp_base_perc_to_dol | RC base percentage | percent of charge | hospital MRF |
| impute: rc_global_gc_hosp_cbsa_base_perc_to_dol | RC base percentage | percent of charge | hospital MRF CBSA |
| impute: rc_global_gc_hosp_state_base_perc_to_dol | RC base percentage | percent of charge | hospital MRF state |
| impute: rc_global_gc_komodo_base_perc_to_dol | RC base percentage | percent of charge | komodo npi |
| impute: rc_global_gc_komodo_cbsa_base_perc_to_dol | RC base percentage | percent of charge | komodo CBSA |
| impute: rc_global_gc_komodo_state_base_perc_to_dol | RC base percentage | percent of charge | komodo state |
| impute: rc_global_per_diem_mult_glos | RC base per diem | per diem | |
| impute: op_gc_komodo_base_perc_to_dol | Outpatient base percentage | percent of charge | komodo npi |
| impute: op_gc_komodo_cbsa_base_perc_to_dol | Outpatient base percentage | percent of charge | komodo CBSA |
| impute: op_gc_komodo_state_base_perc_to_dol | Outpatient base percentage | percent of charge | komodo state |
| impute: op_gc_hosp_base_perc_to_dol | Outpatient base percentage | percent of charge | hospital MRF |
| impute: op_gc_hosp_cbsa_base_perc_to_dol | Outpatient base percentage | percent of charge | hospital MRF CBSA |
| impute: op_gc_hosp_state_base_perc_to_dol | Outpatient base percentage | percent of charge | hospital MRF state |
| impute: cstm_negotiated_rate | CSTM-ALL** | fee schedule | |
| impute: cstm_gc_hosp_perc_to_dol | CSTM-ALL** | percent of charge | hospital MRF |
| impute: cstm_gc_hosp_cbsa_perc_to_dol | CSTM-ALL** | percent of charge | hospital MRF CBSA |
| impute: cstm_gc_hosp_state_perc_to_dol | CSTM-ALL** | percent of charge | hospital MRF state |
| impute: cstm_gc_komodo_perc_to_dol | CSTM-ALL** | percent of charge | komodo npi |
| impute: cstm_gc_komodo_cbsa_perc_to_dol | CSTM-ALL** | percent of charge | komodo CBSA |
| impute: cstm_gc_komodo_state_perc_to_dol | CSTM-ALL** | percent of charge | komodo state |
*The difference between impute: msdrg_base_rate_mult_cms_weight and impute: msdrg_mrf_base_rate_mult_cms_weight is that for impute: msdrg_base_rate_mult_cms_weight, we inferred the base rate by dividing each
MS-DRG posted in MRFs by CMS weights. For impute: msdrg_mrf_base_rate_mult_cms_weight, we identified that a single rate was
posted for 10 different MS-DRG codes.
**"CSTM-ALL" codes are rates that are reported in payer MRF files with billing code type "CSTM-ALL". These rates are not specific to a single billing code, but rather apply to a broader set of services or procedures.
Canonical Rate Type Format​
Enhanced rates use the canonical rate type format: {category}: {rate_source} where:
- Category indicates the processing level (transform, impute)
- Rate Source identifies the specific rate column and transformation used
Common Abbreviations​
- gc: Gross Charge
- hosp: Hospital
- cbsa: Core-Based Statistical Area
- perc_to_dol: Percentage converted to dollar amount
- mult_glos: Multiplied by Geometric Length of Stay
- msdrg: MS-DRG (Medicare Severity Diagnosis Related Group)
- rc: Revenue Code
- op: Outpatient
- cstm: Custom