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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 29-4817. SPECIALTY INPATIENT SERVICES: CALCULATION OF OUTLIER PAYMENTS FOR PS
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4817.1 DHCF shall provide an additional payment for high and low cost outliers.
4817.2 For discharges on or after October 1, 2014, DHCF shall provide an additional payment for specialty inpatient stays when the cost of providing care results in a loss to the hospital that exceeds the high-cost outlier threshold (i.e., high-cost outlier).
4817.3The Marginal Cost Factor shall be used when calculating the high-cost outlier payment and may be adjusted to limit high-cost payments to no more than five percent (5%) of the overall payments.
4817.4 The loss to the hospital shall be calculated pursuant to the following formula:
LOSS
=
COST (ALLOWED CHARGES X COST TO CHARGE RATIO (CCR))
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THE DRG BASE PAYMENT
4817.5 The outlier payment is calculated as follows if the loss exceeds the outlier threshold:
OUTLIER PAYMENT
=
(LOSS – OUTLIER THRESHOLD)
x
THE MARGINAL COST FACTOR
4817.6The PS-APR-DRG payment for the stay shall be the sum of the DRG base payment and the outlier payment, adjusted for transfer pricing, if applicable.
4817.7The CCR used to calculate the cost of a claim shall be hospital-specific as described at Subsection 4814.10.
4817.8 The high-cost outlier threshold shall be reviewed annually and updated when necessary based upon a review of claims history from the District’s previous fiscal year.
4817.9For discharges occurring on or after October 1, 2014, and annually thereafter, DHCF shall adjust payments for extremely low-cost specialty inpatient cases.
4817.10 Low-cost outliers shall be those cases where the gain on the claim (claim costs minus DRG base payment) exceeds the low-cost outlier threshold. Low-cost outliers shall be determined by using the formula identified at Subsection 4817.4. Each claim with a gain that exceeds the low-cost outlier threshold shall be paid at the lesser of the PS-APR-DRG payment amount or a prorated payment.
4817.11DHCF shall set the low-cost outlier threshold at a level that results in four percent (4%) or less of PS-APR-DRG payments being associated with low-cost outlier cases.
4817.12 The low-cost outlier calculation shall use the national average lengths of stay (ALOS) available with the APR-DRG grouper as follows:
LOW-COST OUTLIER PAYMENT
=
(DRG BASE PAYMENT / NATIONAL ALOS)
x
(LOS FOR ELIGIBLE DAYS OF THE STAY +1)
4817.13 If the low-cost outlier payment results in an amount greater than the DRG base payment, DHCF shall disregard the low-cost outlier payment.
4817.14DHCF shall review and calculate the low-cost outlier threshold annually and update where necessary based upon a review of claims history from the previous District fiscal year.
4817.15 For PS-APR-DRG categories where there is insufficient data available to use in calculating a reliable mean or standard deviation, the outlier threshold shall be calculated by multiplying the Weight of the APR-DRG by the Average Outlier Multiplier.
4817.16For each PS-APR-DRG specialty hospital claim that involves a transfer to another hospital or health care facility, DHCF shall pay the transferring specialty hospital the lesser of the APR-DRG amount or prorated payment shall be calculated as follows:
TRANSFER PAYMENT
=
(DRG BASE PAYMENT / NATIONAL ALOS)
x
(LOS FOR ELIGIBLE DAYS OF THE STAY +1)
4817.17For specialty inpatient discharges on or after October 1, 2014, LTCHs shall be paid transition rates. Following submission of the cost report, pursuant to Section 4822, DHCF shall determine allowable costs, notify the hospital of any over- or under-payments made during FY 2015, and establish a final rate for FY 2016.