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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-48. MEDICAID PROGRAM: REIMBURSEMENT |
Section 29-4800. INPATIENT SERVICES:GENERAL PROVISIONS
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4800.1 Effective for inpatient hospital discharges occurring on or after October 1, 2014, Medicaid reimbursement for inpatient hospital discharges shall be on All Patient Refined Diagnosis Related Groups (APR-DRGs) prospective payment system (PPS) for all general hospitals, including acute and pediatric hospitals, except:
(a) Hospitals located in the State of Maryland as identified in Subsection 4800.12;
(b)Specialty hospitals as identified in Subsection 4800.14; and
(c)Hospitals providing inpatient services under certain extenuating circumstances as identified in Subsections 4800.15-16.
4800.2 Inpatient hospital discharges subject to the APR-DRG PPS shall include inpatient hospital stays that last at least one (1) day or more and services provided in Medicare-designated distinct-part psychiatric units and distinct-part rehabilitation units within those hospitals.
4800.3 Payment for each APR-DRG claim, excluding transfer claims, low-outlier claims, or interim claims, shall be based on the following formula:
APR-DRG Hospital-Specific Relative Value (HSRV)
(relative weight for that Diagnosis-related group (DRG))
x
Policy Adjustor (if applicable)
x
District-wide base rate adjusted for Indirect Medical Education (IME), if applicable
=
DRG Base Payment
The final APR-DRG payment may include a high outlier payment adjustment, add-on payments for capital and direct medical education costs, and subtraction of other health coverage or patient share of cost if applicable.
DRG Base Payment
+
High-Outlier Payment Adjustment
+
Add-on Payments for Capital and Direct Medical Education Costs
-
Other Health Coverage
-
Patient Share of Cost
=
APR-DRG PPS Payment
4800.4 The following methods and standards may apply under APR-DRG PPS:
(a) The APR-DRG classification system as contained in version 31 of the 3M™ APR-DRG Classification System Definitions Manual, and any subsequently adopted versions, shall apply for purposes of calculating reimbursement for all inpatient discharges, including specialty, under this chapter;
(b) The District may update the APR-DRG grouper biennially;
(c) As described under Section 4801, APR-DRG PPS shall include a single, District-wide base rate for all general hospitals providing inpatient hospital services;
(d) As described under Section 4802, the implementation of APR-DRG PPS shall include an annual calculation of hospital-specific cost-to-charge ratios (CCRs);
(e) As described under Section 4803, the implementation of APR-DRG PPS shall include a calculation of the District-wide cost and average cost per discharge;
(f) As described under Section 4804, the base rate may include Indirect Medical Education (IME) for hospitals located within the District;
(g) As described under Sections 4805 and 4807, APR-DRG PPS may include Direct Medical Education (DME) as well as capital add-on payments;
(h) As described under Section 4806, APR-DRG PPS reflects a severity of illness (SOI) in its associated relative weight;
(i) As described under Section 4808, APR-DRG PPS may include an adjustment to reimbursement for high-cost and low-cost outliers;
(j) As described under Section 4809, the implementation of APR-DRG PPS may include policy adjustors;
(k) As described under Section 4810, hospitals located in an Economic Development Zone (EDZ) shall receive an increased reimbursement rate;
(l) As described under Section 4811, for each claim involving a transfer to another general hospital, DHCF shall pay the transferring hospital the lesser of the otherwise applicable DRG base payment amount or a prorated payment based on the ratio of covered days to the average length of stay associated with APR-DRG;
(m) As described under Section 4812, reimbursement for short-term stays shall be limited; and
(n) As described under Section 4813, implementation of APR-DRG PPS shall include consideration of third party liability and patient cost sharing.
4800.5 All non-emergency, inpatient admissions shall require prior authorization.
4800.6 Medicaid payment adjustments for Provider Preventable Conditions, including Health Care-Acquired Conditions pursuant to 29 DCMR § 9299 shall be processed and paid in accordance with the criteria for payment adjustment for provider preventable conditions described under 29 DCMR §§ 9200 et seq.
4800.7 Outpatient diagnostic services provided by any general hospital, not located in Maryland, one (1) to three (3) days prior to an inpatient admission at the same hospital shall not be separately payable and shall be billed as part of the inpatient stay.
4800.8 All hospital outpatient services that occur on the same day as an inpatient admission at the same general hospital, not located in Maryland, shall be considered part of the inpatient stay and shall not be payable separately.
4800.9 A general hospital located in the District shall be required to submit cost reports and comply with audits in accordance with the requirements described at Section 4822.
4800.10 All general hospitals that provide inpatient services shall maintain records in accordance with the requirements described at Section 4822.
4800.11 Hospitals that provide inpatient services shall be subject to the appeal and administrative review requirements described at Section 4822.
4800.12 General hospitals located in Maryland shall anticipate reimbursement in accordance with Health Services Cost Review Commission (HSCRC)’s All-Payer Model Contract with Center for Medicare and Medicaid Innovation, or its successor, for inpatient hospital discharges.
4800.13 Out-of-District general hospitals, not located in Maryland, shall be reimbursed by DRG. The DRG base rate for out-of-District hospitals is the District-wide Base Rate, without IME.
4800.14 Specialty hospitals, identified at Section 4814, shall be reimbursed either on a per diem or a per stay basis under APR-DRG PPS for inpatient hospital discharges.
4800.15 Where the Director of DHCF determines extenuating circumstances, including but not limited to closure or bankruptcy, exist within the District’s specialty hospital system, a general hospital may receive reimbursement either on a per diem or a per stay basis under APR-DRG PPS for services provided to a patient who would have been transferred from the general hospital to a Long Term Care Hospital, if a bed were available.
4800.16 Reimbursement under Subsection 4800.14 may be adjusted based on the acuity of the patient to ensure appropriate payment.
4800.17 Appeal and administrative review rights, and cost reporting, auditing, and record maintenance requirements, identified at Sections 4822-4823, shall apply to all general hospitals receiving reimbursement under APR-DRG PPS.