MDClarity · Pricing engine inventory

What the pricing rules actually are

The legacy engine prices a charge by running an ordered program of typed calculations. There are 45 types, a gating layer with two competing mechanisms, and an escape hatch into raw T-SQL that a third of all fee logics reach for. This is what is in there, and where the weight sits.

calculation types

1,612

fee logics

30,052

calculations

268

distinct SQL bodies

customers

Foundations · 01

The shape of a rule

A FeeLogic is the unit of configuration: an ordered program that turns charges into an allowed amount. Everything else is a layer inside it.

1 · Resolution

Contract maps bind the fee logic to a facility × insurance × bill type × date rangetuple. At most one fee logic may match.

2 · Base calculations

Ordered. First match wins per charge — they do not sum. A fee logic with eleven base calcs is a waterfall with a fallback, not an accumulation.

3 · Adjustments

Ordered, and these do compose — each reads the running amount left by the one before it.

4 · Sequestration

Never appears in the config. Triggered by a boolean on the fee logic, applied after benefits aggregation — and it loops back.

Where it loops

Sequestration is not a downstream step. The benefits aggregator computes each charge's patient/insurance split; sequestration reads that split to derive a patient ratio, shrinks the allowed amount, then re-runs the aggregator over the shrunk numbers. Anything that prices in one shot will not match legacy on Medicare-based charges.

Inventory · 02

Which types each customer uses

Every customer against every calculation type that appears in production. Cell shading is log-scaled; blank means the customer does not use that type at all. Rows link to the customer's contracts, columns to the type.

Customer	ModifierAdj	PctOfFees	LesserOfAdj	MedMultProcedureAdj	MedMultRadiologyAdj	MidLevelProviderAdj	MedMultEndoscopyAdj	MedRVU	FlatPctOfChgs	FlatFee	ChgLevelSqlAdj	MedDrug	SqlExpression	MedBilateralSurgeryAdj	MedLab	MedDME	MultProcedureAdj	MedMultTherapyAdj	CalcBuilder	MedAnesthesia	MedASC	MultEndoscopyAdj	PctageAdj	MultSurgeryAdj	CaseRate	FlatPctageAdj	MedMultOphthalmologyAdj	MedMultSurgeryAdj	PctOfChgs	ExcludedChgAdj	MultRadiologyAdj	BilateralSurgeryV2Adj	MedOPPSCapAdj	MultPhysiotherapyAdj	NotToExceedAmountAdj	BCBSMultTherapyAdj	BilateralSurgeryAdj
ECP	2483	179	188	186	188	188	188	108	112	235	188	123	3	184	71	69			16		35			31	8		49		5	1
OneGI	1755	293	150	152	149	145	88	37	51	61	132	40	14	145	37	37		1	6	68	10			1				2
SGP	1964	156	140	140	140	137	140	118	33	152		73	10		63	54			58		34				5	1			2
MNEye	803	233	127	41		19	14	16	59	29	67	15	199		14	14	27				18	18	35	37				44		26
OrthoAlliance	1191	211	97	92	4	42	79	31	74	107	55	27	3		15	17	27	72	19	9	18			5	42	54	2			4						1
RIA	1345	230	104	103	96		103	126	40	4	1	73	1	6	68	70			15	5									3		7	15	10
Commonwealth	1005	155	77	77	77	59	77	161	21			52	4	8	40	21		16	13	26	4					6			2	6
EyeSouth	154	129	51	5	5	5	5	15	18		35	15	28		15	15	60		20			5	11						17
ARSA	296	43	41	41	41	22		19	42			19	2	41	19	19		41			2														1
Femwell	86	138	20					4	114		16	2	200		2	2	65					7	5		6					1
EugeneGI		41	30						1								39
PAA									4				39
StrideCare	485	35	36	37	37	33	37	6	3	36	2	6	2	3	6	6				2	3								1
HeatonEye	486	41	37	28	35	28	28	17	16	1		13	18		13	13	9				10	9	9					1	5		9
USDH	495	64	38	37	38	37	38	58	2	4		38			17	17	1		5	19
PrecisionHealth	330	30	31	30	30	30	30	33	10	30	30	29	1	30	30	29				2
TFOC	325	125	29						24		10		3				29					28	18											4
JewishBoard	220	14	16	27	16	11	16	3	3		16	3	12	16	3	3
MiddletownMedical	57	60	28	33	22	68	4	36	21	20	2	25		28	23	19	1	12	16
SeaRad	102	72	14					6	13		6		2				14		3			8	3						3
ISpine	245	42	25	29	22	41	17	13	16		22	6		21	10	6		19		13	5							2
TheOregonClinic	34	6	24	24	24	24	3	14	23			11		24	11	8		3		3	11														2
USHP	263	13	23	23	23	23	23	8	2	7	22	16	6	23	8	8				8	1			1					1
MannEye	208	17	16	16	16	16	16														1
SouthSoundRadiology	160	25	13					8	13	1	12	3	6		3	2	17	13	1			16		1					3								1
CCP	6	16	13					1					3				6						7						1
NWDerm	104	6	12	7	8	9	8	8	5			8		1	8	8				6
HillsboroEye	132	6	12	12	12	11	12	32	11	12	12	10		12	11	9				1									1
Monarch	143	11	11	11	11	11	11	1				1			1	1
SWOrofacial	104	20	8		8	8	8	1	1	1		1	4		1	1	8
SunLife		10	4							1															1
PPRM		2											1
Wildflower		2

Reading a row gives a customer's whole methodology mix; reading a column shows how widely a methodology is adopted. The customer table adds the blockers.

Caveats · 03

Dead config — filter it out before you count anything

Three classes of configuration exist in the data but can never take effect. All three are invisible in the source XML; a dead entry and a live one look identical.

Measure	Count	Note
fee logics	1,612
unreachable (no contract map)	259	excluded from analysis by is_reachable
of those, map exists but selects nothing	76	empty insurance/billtype/facility
of those, scenario models	28	expected to be unreachable
SupersededBy edges	1,733
forward refs (never fire)	233	dead config
dangling (no such calc)	0	dead config
contract map overlaps (facility-expanded)	1,961	onboarding blockers
distinct fee-logic pairs	30
customers affected	9