Standard Loading Assumptions

FinThrive loads contracts based on standard loading assumptions unless:

  • Your facility identifies exceptions to these assumptions
  • The contract language expressly states otherwise
  • The work-list is providing information to prove otherwise

Knowing the standard loading assumptions helps you to understand our re-pricing calculations as you review the contract profiles and work lists.

  1. FinThrive ranks service types to cover multiple services on a claim. High priority service types have a lower ranked number. Specifically, the following ranking applies:
    • Typically, a higher reimbursement amount =
      Higher priority =
      Lower numerical rank
      • PTCA @ $5000.00 ranks a higher priority and reimburses first (lower number, for example 20) than a CCATH @ $3000.00 (higher number, for example 25)
      • The order of reimbursement for basic outpatient services is Surgery, Observation, ER, then other services (supplies, RX, labs, and so on)
    • Case rates take priority over per diem rates and reimburse first.
      • A Cardiovascular Procedure case rate of $12,000.00 ranks as a higher priority (lower number) and reimburses before a Per Diem rate.
    • An IP Case rate, paid at a percentage of charges, is ranked as a higher priority (lower number) before an IP case rate.
  2. Service Type Definitions
    • OPSurg is defined as a claim billed with revenue codes 360-369, 490-499, or a claim billed with a combination of Rev codes 360-369, 490-499, 750, and any CPT code listed in the CMS ASC Groupers.
      • Claims that contain Gastrointestinal CPT codes (listed in the ASC Groupers) and billed with revenue code 750 reimburse at the OPSurg rate.
      • Claims that contain a surgical revenue code without including a surgical CPT code reimburse at the OPSurg “Ungroup able” or “Default” rate.
    • Newborn services are defined by revenue codes 170-179 as follows:
      • Normal Newborn or Well Baby = 170-171
      • Sick Baby or Transitional Nursery = 172-173 (if no rate is specified, these codes will be included with Newborn)
      • NICU = 174-175
      • Boarder Baby = 179

    EXCEPTION: Some customers bill differently for Newborn services. This should be something identified in the implementation process.

    • FinThrive has a large group of “Universal” service types that include the standard codes generally billed by most facilities. If your contract does not specify codes for a particular service, the Universal definition is used, if available.
  3. Reimbursement Methods
    • All OP – a default reimbursement for any charges on Outpatient claims not otherwise reimbursed or excluded. The Condition Expression for this service type is “1” which captures all remaining charges.
    • Should your contract list services that are not covered under that particular contract, FinThrive sets up those services to reimburse at 100% of total billed charges and flags those accounts for your manual review.
    • OPSurg (NOTE * this is only when detailed language is not provided in contract or by facility)
      • If no multiple surgery rules are indicated, the primary (highest payment) procedure is reimbursed @ 100% of the indicated case rate. NO additional procedures are reimbursed.
      • If a multiple surgery rule is indicated, there is no limit placed on the number of procedures to be reimbursed (unless stated in the contract that up to _ # of procedures are reimbursed).
      • If the rule is 100/50/25 and there are 5 procedures on a claim they will pay 100/50/25/25/25.
      • If there is a default percentage for claims without grouped codes, the percentage reimbursement is applied to gross charges.
      • If there is NO default percentage, and a claim has multiple surgical codes, including codes not listed in the Groupers, only the codes in the groupers are reimbursed.
    • Observation reimbursement assumes that the units on the UB are equal to hours.
    • OP Diagnostic Services, such as MRI, CT, Lab, and so on.
      • Reimbursement is by line item and generally per unit.
      • Ranking is set at a lower priority (higher number) and does not reimburse in addition to case rates (such as ER, OPSurg).
      • If contrast material or other supplies are billed separately, they reimburse at the All OP rate unless a contract specifically states services are inclusive.
    • Pass-through Items – Many services that reimburse in addition to per diem or case rate payments are placed in the Pass-through section of the contract. This section is not reserved for “Cost pass-through” items exclusively.
    • Pass-through items are set up to reimburse for both inpatient and outpatient claims, unless otherwise noted.
    • Med/Surg – Default reimbursement for Inpatient claims.
      • Any services without specific rates will reimburse at the Med/Surg rate.
      • If there are no SNF or Rehab services types in the profile, these claims reimburse at the Med/Surg rate.
      • If a contract lists a rate for “All other services” as well as a Med/Surg rate, either the Med/Surg or “All other services” (if pertaining to a specific service), must be defined. Otherwise, it will not be addressed in the re-pricing process.
    • OB rates are assumed to be a Mother/Baby combined rate unless the contract lists a Normal Newborn rate.
      • Normal Newborn service type is added to the profile with a $0.00 payment to keep Baby's claim from being reimbursed at the Med/Surg rate.
      • Mother and Baby case rates are not split. Expected payment is based on the Mother's account, and Baby's account reimbursement is $0.00.
      • When a contract states a rate for multiple births, the additional payment is on the Mother's account.
    • Second Dollar Stop Losses reimburse the per diem rate up to, but not including, the day the threshold is met, unless specifically identified in the contract.
      • If the threshold limit is met on day 5 of a stay, the per diem reimbursement is paid for 4 days.
      • Pass-through items are not excluded from that threshold calculation unless specified in the contract.
  4. Government Program Nodes
    • Government Nodes (Medicare/Medicaid/TRICARE) are loaded per the Government Regulations. These nodes are not altered based on payments and adjustments from the payor.
    • Medicare Node – Requires a few facility specific factors (IME, DME, Cost to Charge Ratio, and so on). When these factors are updated, it is imperative that FinThrive receives the updates as soon as the documentation is received by the hospital from the Fiscal Intermediary (FI).
    • Facility maintains responsibility of monitoring and submitting rate and policy changes to FinThrive.
    • Should the hospital have provider numbers for Psych, Rehab or SNF, but the worklist results identify that the payor is paying the Acute factors for those account types, FinThrive will change the provider number for those particular services to match the Acute number.
  5. Specialty Profiles (such as Behavioral Health)

If the Contract lists reimbursement for specific services AND there is no Default reimbursement indicated in the Contract, FinThrive will set up All IP and All OP to reimburse at 100% of billed charges and to be flagged for manual review, so those claims do not fall to your exceptions report.