Columbus Regional Healthcare System utilizes Cerner-Community Works as its third-party information system for patient billing.
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 Columbus Regional Healthcare patients use our Price Estimation tool for personalized cost estimates for Columbus Regional Healthcare hospital services.
Examples of potential contracted rate differences include but are not limited to the following:
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 Columbus Regional Healthcare System received notification of the rate change.
Please consult publicly available Medicare rates for additional rate information.
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.
If more than one procedure is performed during a single visit, the contracted rate for the secondary and subsequent procedures could be lower than a single procedure rate, depending on the payer contract terms. The machine-readable file(s) contains the single procedure rate, which may be higher than any applicable multiple procedure rate.
When a payer contract has multiple negotiated rate methodologies, the contracted rate for some services can take precedence over rates for other services, depending on the mix of services on a claim. The machine-readable file(s) will reflect the contracted rate for a single service, which may be different from the actual rate if multiple services are provided to an individual.
Certain drug charges are maintained in the CDM and are therefore included on the primary tab of the machine readable list of charges file. The payer-specific negotiated charges for each hospital are shown for drugs that are contained in the CDM, although these drugs are not a comprehensive representation of all drugs contained in a hospital’s pharmacy system.
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.
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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