Payer Specific Negotiated Charges
Latest Payer-Specific Negotiated Charges
Managed care payers / plans pay inpatient rehabilitation hospitals based on an overall rehabilitation service category or program, also referred to as a “service package” by CMS. A service package payment would apply when the managed care plan pays the hospital on a per day basis (per diem) or on a case specific basis (per discharge) or as a flat rate. For these three payment types, specific procedures and tests, etc. are not paid individually. All the relevant services are grouped together and paid as a service package. If the managed care plan pays the hospital according to a discount off of total billed charges, then the discount is applied to every line on the claim in order to calculate the total payment made to the hospital. The billing code(s) used to determine payment for service packages (per diem and per discharge and flat rate contracts) are most commonly the Room and Board (R&B) revenue codes. Room and Board revenue codes include revenue codes 118; 120; 128; 138; 148 and 158. Other Revenue Codes will appear on the billing claim but they do not impact the payment. Individual billing codes for all the services listed on a claim would be used to determine payment for contracts paid on a discount off of billed charges.
On average a patient will stay 14 days in an inpatient rehabilitation hospital this varies by each patient. Therefore, if the managed care plan pays on a per day basis you would need to multiply the per day amount by 14 to get an estimate of the total payment. The typical inpatient rehabilitation service category or program (service package) will include:
- Room and Board Services (private or semi-private room)
- All related therapy services (i.e. physical; occupational; speech, etc.)
- Routine supplies
- Routine medications
- All nursing services
Please note that physician services are not included and are billed separately by each individual physician and paid separately by the managed care plans. The information provided here does not include any physician services.
On a less frequent basis other services may be required and may be paid in addition to the services listed above. These services may be billed by a different provider. Examples of these additional services may include but are not limited to
- Special equipment
- High cost pharmacy items
- Dialysis treatments
- High cost diagnostic services such as a CT Scan or MRI
If “NA” is listed under the plan you are researching you will need to scroll down the column to find the relevant pricing category for that particular plan. If you do not see a specific plan listed, our hospital may not have a contract with that particular plan. If you have any questions please call us at (803) 254-7777 and ask to speak with an admissions representative and we will provide you with the most current information available.
Download our listing of Payer Specific Negotiated Charges below (csv):
Latest Shoppable Services
The Centers for Medicare Services (CMS) has defined a “shoppable service” as a service package that can be scheduled by a health care consumer in advance. Shoppable services are typically those that are routinely provided in non-urgent situations that do not require immediate action or attention to the patient, thus allowing patients to price shop and schedule a service at a time that is convenient for them.
The Centers for Medicare and Medicaid Services (CMS) published a listing of 70 Shoppable Services listed with their primary billing code(s) which are required for hospitals to display their negotiated charges by each managed care plan. If a particular service is not offered by our hospital, a “NA” will be displayed. The required services are included below in the Shoppable Services file. In addition to the 70 required services, hospitals are required to list 230 additional shoppable services for a total of 300 shoppable services. We have listed the most common services or service packages we provide with the corresponding negotiated charges paid by the managed care plans in the Shoppable Services file.
If you have any questions regarding the information provided please call (803) 254-7777 and ask to speak with an admissions representative.
Download our listing of Shoppable Services below (csv):