Project Summary: Health Plan Rate Analysis
Category: Health Plan Rate Setting
Background: The Colorado Network was working with one of its network members to avoid paying higher costs to a health plan, which would force that member to increase fees.
Objective: Analyze high cost/high utilization DRGs by payer to determine appropriate rates with health plans.
Data Analyzed: Average charged, average allowed, average plan paid, average member liability for selected DRGs by Payer for Rural Hospitals and The Colorado Network member.
Results: A health plan intended to capitate San Luis Valley Health’s (SLVH) rates for many high-volume inpatient DRG’s as well as Outpatient radiology tests and ER visits. With SLVH’s very high indigent care, charity care, and Medicaid/Medicare population, this would not have been financially viable. CO APCD data provided proof that SLVH charges are well within rural Colorado comparative pricing and in many cases even lower. As a result, the health plan dropped their rate proposal and has not proposed approach this since.