By Brian Cotter
901% of Medicare. Or 1,653%. Same rate. Different denominator. I ran the math at NYP. I pulled every payer rate for MS-DRG 871 (Septicemia) from NYP’s price transparency file and benchmarked each against four versions of Medicare.
Anthem BCBS pays $216,791 for this DRG at NYP.
- 1,653% of National ($13,117)
- 901% of Hospital No Supp ($24,052)
Same rate. The % of Medicare swings by 750 percentage points depending on which denominator you use.
Which denominator to use.
The Hospital benchmark without supplementals reflects the DRG weight, the hospital’s wage index, and the capital payment. That is it. No teaching subsidy. No uncompensated care. No quality penalties.
Those supplemental components are policy driven. They have nothing to do with treating your patient. The denominator should reflect what the hospital is paid for the clinical encounter, not what Medicare layers on for policy reasons.
The National and Market benchmarks blend wage indexes and average across hospitals. Neither is specific to the facility you are negotiating with.
If you run the CMS IPPS Pricer yourself, the total output is $27,075. That includes $2,238 in passthrough (direct GME, organ acquisition) allocated per discharge regardless of DRG. That has nothing to do with sepsis. Do not use the pricer total as your denominator.
The spread at NYP is enormous.
Anthem BCBS pays 9.0x Medicare for this DRG. 1199SEIU pays 1.9x. Same hospital. Same DRG. Both are commercial plans.
Medicare Advantage plans pay $17,923 to $19,432. That is 0.8x Medicare. MA plans are already paying below the Hospital No Supp benchmark at this hospital.
“200% of Medicare” at NYP produces two very different numbers depending on the denominator:
- 200% of National = $26,234
- 200% of Hospital No Supp = $48,104
$21,870 difference per case. On one DRG.
The benchmark is only step one.
Getting the right denominator into your analysis and negotiation is critical.
But it does not matter if the claims are not adjudicated to those terms.
The benchmark version, the components included, and the components excluded need to be captured in the agreement language. Then it needs to be audited.
If the contract says Hospital No Supp but the TPA runs the full pricer output, you are overpaying on every claim and nobody catches it until someone pulls the data.
We have these benchmarks ready.
Every hospital. Every DRG. Four benchmark versions. We can pull any hospital’s published rates and show you exactly where your contract falls.
Reach out and I will send you a sample.
brightspotinsights.com
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Rate Source: 133957095_newyork-presbyterian-hospital_standardcharges.json (CMS Hospital Price Transparency MRF v3.0.0, last updated 2026-03-31)
Benchmark Source: Bright Spot Insights CMS FY26 IPPS Benchmark Dataset (FY2026_IPPS_Base_DRG_Payments_All_Hospitals_Enriched_v2.csv)
