Calculator Inputs
Example Data Table
| Scenario | Claims | Diversion | Repeat | Network | Gross per-claim | Employer total |
|---|---|---|---|---|---|---|
| Baseline (discounted) | 25 | 0% | 0% | In-network | $3,613.50 | $7x,xxx |
| 10% diversion to urgent care | 25 | 10% | 0% | In-network | $3,613.50 | $6x,xxx |
| Out-of-network with repeats | 25 | 0% | 8% | Out-of-network | $7,469.00 | $1xx,xxx |
Formula Used
Base per-claim
Base = Facility + Professional + Diagnostics + Ambulance + Meds + Observation + Imaging
Allowed per-claim
Allowed = (Base ÷ BilledToAllowed) × NetworkFactor × TrendFactor × AcuityFactor + AdmitRate × AdmitAddOn
Utilization savings
AllowedSaved = Allowed × (1 − UMSavings%)
Gross per-claim (severity option)
Gross = AllowedSaved × (HighCostFactor if AllowedSaved ≥ Threshold)
Member pay per-claim
Member = min(OOPMax, Copay + min(Deductible, Gross−Copay) + Coins% × max(0, Gross−Copay−Deductible))
Claims after diversion and repeats
ERClaims = round((Claims − Diverted) × (1 + Repeat%))
EmployerTotal = PlanER + DivertedCare + Admin + Taxes + Contingency + SLPremium + Indirect
This model is simplified for planning. Deductible, OOP max, and stop-loss are applied per claim. Real plans often have accumulators and family-level rules.
How to Use This Calculator
- Enter claim count and average per-claim component costs.
- Use the severity section for imaging, observation, and admissions.
- Set network discount or out-of-network multiplier and trend horizon.
- Optional: add diversion, repeat visits, and utilization savings.
- Fill plan cost share and optional per-claim OOP maximum.
- Add overhead, stop-loss premium, and indirect productivity loss.
- Press Calculate to view totals, chart, and exports.
Cost structure assumptions for an average ER visit
The model starts with an average visit built from facility, professional, diagnostics, ambulance, and medications. For planning, many teams treat facility as the largest driver, with diagnostics next when imaging is common. Observation hours and CT/MRI inputs convert intensity into dollars using counts and rates, so you can align assumptions with contract schedules or prior claims.
Network pricing and allowed amount conversion
In-network pricing applies a discount percentage, while out-of-network applies a multiplier. If your inputs are billed charges rather than allowed, the billed-to-allowed factor converts charges to an allowed estimate before network and trend adjustments. This supports “what-if” comparisons when a dataset mixes billed and paid views. Keep the same conversion logic across scenarios to preserve comparability.
Trend horizon and severity stress testing
Annual medical trend compounds across the month horizon. A 6% annual trend over 12 months yields roughly a 1.06 factor; over 6 months it is near 1.03. Acuity adds a case-mix factor (low to critical), and a high-cost threshold can trigger an intensity uplift. Together, these controls help quantify volatility from small numbers of severe encounters.
Member cost share, plan exposure, and stop-loss logic
Member pay is calculated per claim using copay, deductible, and coinsurance, with an optional per-claim out-of-pocket cap. Plan-paid cost is the remainder, optionally capped by a stop-loss attachment amount to represent an exposure limit. The approach is simplified and does not model annual accumulators, but it is effective for consistent scenario planning and budgeting discussions.
Program levers: diversion, utilization savings, and repeats
Diversion reduces ER claims and adds a lower-acuity cost defined as a percentage of ER per-claim. Utilization savings reduces allowed cost after network, trend, and severity, representing steering, coding, or prior-authorization effects. Repeat visits inflate episode volume. The sensitivity graph shows how employer totals shift as diversion increases, supporting program sizing decisions.
FAQs
1) What does the billed-to-allowed factor represent?
It converts billed charges into an allowed estimate. If billed totals are typically 1.4× allowed, set 1.40 so inputs are divided before network and trend adjustments.
2) Why is deductible applied per claim here?
The calculator is designed for transparent scenario planning. Real plans use annual accumulators; per-claim modeling keeps comparisons consistent across benefit designs and avoids hidden carryover assumptions.
3) How do I set the diversion cost percent?
Enter the expected alternative-site cost as a percent of ER per-claim. Urgent care or tele-triage pathways are often modeled at 20%–50%, then refined using vendor fee schedules or paid-claim benchmarks.
4) What does utilization savings reduce?
It reduces the allowed amount after network, trend, and acuity adjustments. Use it to represent steering, coding fixes, prior authorization, or negotiated improvements that lower allowed cost without changing encounter volume.
5) How should I interpret the stop-loss attachment?
It caps plan-paid cost per claim. Amounts above the attachment are treated as recovered. This is a modeling proxy for per-claim exposure and does not replace carrier reporting or contract terms.
6) Can I show results in PKR or EUR?
Yes. Select a currency and provide an FX rate in local per USD. Outputs are converted for display, while calculations remain on a USD basis for consistent scenario math.