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DEPARTMENT OF HEALTH CARE FINANCE
NOTICE OF FINAL RULEMAKING
The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2008 Repl.)) and section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2008 Repl.)) hereby gives notice of the adoption of an amendment to chapter 48 (Medicaid Reimbursement for Inpatient Hospital Services) of title 29 (Public Welfare) of the District of Columbia Municipal Regulations (DCMR). The purpose of this rule is to amend Medicaid reimbursement to hospitals to reduce hospital overpayments by updating the base payment rates for inpatient hospital services for hospitals participating in the Medicaid Program.
The effect of this rule is to provide mechanisms to permit the annual updating of base rates, hospital add-on rates and outlier thresholds to provide a payment to cost ratio that does not exceed ninety-eight percent (98%) for each hospital’s base year. In addition, this rule provides DHCF with discretion to adjust each hospital’s base year payment using an inflation factor obtained from the Centers for Medicare and Medicaid Services (CMS) Hospital Market Basket Index. To promote timely filing of cost reports, if a hospital does not submit timely a complete cost report, this rule provide that an amount equal to seventy-five percent (75%) of the hospital’s payment for the month the cost report was due shall be withheld each month until the cost report is received. This rule also change the reimbursement methodology for certain non-DRG, specialty hospitals in Maryland to bring their payments in line with similar specialty hospitals in the District of Columbia. Finally, this rule provide that each hospital will receive written notice of any adjustment to its payment rates and if it disagrees, may request administrative review to the Agency Fiscal Officer, followed by an appeal to the Office of Administrative Hearings (OAH).
The corresponding amendment to the District of Columbia State Plan for Medical Assistance (“State Plan”) was approved by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) on November 23, 2012 with an effective date of October 1, 2012, after receiving approval from the Council of the District of Columbia pursuant to the Fiscal Year 2013 Budget Support Emergency Act of 2012, effective June 22, 2012 (D.C. Act 19-385; 59 DCR 7760).
A notice of emergency and proposed rulemaking was published in the DC Register on September 21, 2012 (59 DCR 011021
011007). No comments were received and no substantive changes have been made. These final rules were adopted by the Director on December 20, 2012. These rules shall become effective on the date of publication of this notice in the D.C. Register.Chapter 48 of title 29 of the District of Columbia Municipal Regulations is amended to read as follows:
Chapter 48 MEDICAID PROGRAM: REIMBURSEMENT
4800 MEDICAID REIMBURSEMENT FOR INPATIENT HOSPITAL
SERVICES
4800.1 Effective for inpatient hospital discharges occurring on or after the effective date of these rules, Medicaid reimbursement for inpatient hospital services shall be on an All Patient-Diagnosis Related Group (APDRG) prospective payment system discharge basis for all hospitals in the District of Columbia except:
(a) Washington Specialty-Hadley Memorial Hospital, Washington Specialty-Capitol Hill Hospital, Hospital for Sick Children, and National Rehabilitation Hospital as described in section 4810.1;
(b) Psychiatric hospitals as described in sections 4810.2 and 4810.3;
(c) Hospitals located in Maryland as described in section 4800.5; and
(d) Other out-of state hospitals as described in section 4800.6.
4800.2 Hospital inpatient services subject to the APDRG prospective payment system shall include inpatient hospital stays that last only one (1) day and services provided in Medicare-designated distinct-part psychiatric units and distinct-part rehabilitation units within those hospitals.
4800.3 Payment for each APDRG claim, excluding transfer claims as described in section 4809, shall be based on the following formula:
APDRG Service Intensity Weight for each claim
X
Final Base Payment Rate
+
Add-on Payments for Capital and Direct Medical
Education Costs
+
Outlier Payment
4800.4 The Department of Health Care Finance (DHCF) has adopted the APDRG classification system as contained in the 2009 APDRGs Definition Manual, Version 26, for purposes of calculating the rates set forth in this chapter. Subsequent versions may be adopted after publication, if DHCF determines a substantial change has occurred.
4800.5 Effective for inpatient hospital discharges occurring on or after October 1, 2012, hospitals located within the State of Maryland shall be reimbursed a percentage of charges, except that:
(a) Adventist Behavioral Health (Potomac Ridge), Sheppard Pratt, and any other specialty psychiatric hospital shall be paid the lesser of the hospital’s submitted charges or the rates paid to hospitals in 4810.3; and
(b) Adventist Rehabilitation Hospital and any other specialty rehabilitation hospital shall be paid the lesser of the hospital’s submitted charges or the TEFRA Target Rate for National Rehabilitation Hospital as described in section 4810.1.
4800.6 With the exception of the State of Maryland, out of state hospitals shall be reimbursed as a Diagnosis Related Group (DRG) payment. The DRG base rate for out of state hospitals shall be the weighted average of the base rates for hospitals in the Community Hospital peer group, as defined in subsection 4801.1(b).
4801 CALCULATION OF BASE PAYMENT RATES
4801.1 For purposes of establishing the base payment rates, the participating hospitals located in the District of Columbia shall be separated into three (3) peer groups as follows:
(a) Children’s Hospitals: Children’s National Medical Center;
(b) Community Hospitals: Providence Hospital, Sibley Hospital, and United Medical Center; and
(c) Major Teaching Hospitals: Georgetown University Hospital, George Washington University Hospital, Howard University Hospital, and Washington Hospital Center.
4801.2 Effective October 1, 2012, the base year period shall be each hospital’s fiscal year that ends prior to October 1, 2011.
4801.3 Effective October 1, 2012, the base payment rate for each hospital shall be developed utilizing costs from each hospital’s submitted cost report for the fiscal year that ends prior to October 1, 2011, as well as facility case mix data, claims data, and discharge data from all participating hospitals for the District’s fiscal year ending September 30, 2011.
4801.4 Effective October 1, 2013, and annually thereafter, the base payment rate for each hospital shall be developed utilizing costs from each hospital’s submitted cost report for the fiscal year that ends prior to October 1 of the prior calendar year, as well as facility case mix data, claims data, and discharge data from all participating hospitals for the District’s most recently completely fiscal year.
4801.5 Effective October 1, 2012, and annually thereafter, the costs set forth in subsection 4801.3 shall be updated by applying the cost-to-charge ratio determined by each hospital’s submitted cost report for the fiscal year that ends prior to October 1 of the previous calendar year.
4801.6 The final base year payment rate for each hospital shall be equal to the peer group average cost per discharge calculated pursuant to section 4803, plus the hospital-specific cost per discharge of indirect medical education calculated pursuant to section 4804, subject to a gain/loss corridor as set forth in subsection 4801.7.
4801.7 Subject to federal upper payment limits, each hospital’s base year payment rate shall not exceed a rate that approximates an overall payment to cost ratio of ninety-eight percent (98%) for the base year. The payment to cost ratio is determined by modeling payments to each facility using claims data from the District’s most recently completely fiscal year.
4802 CALCULATION OF THE HOSPITAL-SPECIFIC COST PER DISCHARGE
4802.1 The hospital-specific cost per discharge shall be equal to each hospital’s Medicaid inpatient operating costs standardized for indirect medical education costs and variations in case mix, divided by the number of Medicaid discharges in the base year data set and adjusted for outlier reserve.
4802.2 Medicaid inpatient operating costs for the base year period shall be calculated by applying the hospital-specific operating cost-to-charge ratio to allowed charges from the base year claims data. The cost-to-charge ratio shall be calculated in accordance with 42 C.F.R. § 413.53 (Determination of cost of services to beneficiaries) and 42 C.F.R. §§ 412.1 through 412.125 (Prospective payment systems for inpatient hospital services), and as reported on cost reporting Form HCFA 2552-10, Worksheet C, Part 1 (Computation of ratio of cost to charges), or its successor, except that organ acquisition costs shall be excluded.
4802.3 Cost classifications and allocation methods shall be made in accordance with the Department of Health and Human Services, Health Care Finance Administration Guidelines for Form HCFA 2552-10 and the Medicare Provider Reimbursement Manual 15 or any subsequent guidance issued by the federal Department of Health and Human Services.
4802.4 Medicaid inpatient operating costs calculated pursuant to subsection 4802.2 shall be standardized for indirect medical education costs by removing indirect medical education costs. Indirect medical education costs shall be removed by dividing Medicaid operating costs by the indirect medical education factor set forth in subsection 4802.5.
4802.5 The indirect medical education adjustment factor for each hospital shall be the factor calculated by Medicare for each hospital based on the hospital cost report for the base year period as described in subsection 4801.2.
4802.6 Medicaid inpatient operating costs calculated pursuant to subsection 4802.2 shall be standardized for variations in case mix by dividing Medicaid operating costs standardized for indirect medical education pursuant to subsection 4802.4 by the appropriate case mix adjustment factor set forth in subsection 4802.7.
4802.7 The case mix adjustment factor for each hospital shall be equal to the sum of the relative weights of each discharge in the base year, divided by the number of discharges in the base year. The case mix adjustment factor calculated pursuant to this section shall be adjusted by two point five percent (2.5%), which accounts for an expected change in case mix related to improved coding of claims.
4802.8 The hospital-specific cost per discharge adjusted for indirect medical education and case mix shall be reduced by a net one percent (1%), which takes into account five percent (5%) of the cost reserved for payment of high-cost claims and four percent (4%) of the cost restored to account for the reduction in payment for low-cost claims.
4803 CALCULATION OF THE PEER GROUP AVERAGE COST PER DISCHARGE
4803.1 The peer group average cost per discharge shall be equal to the weighted average of the hospital specific cost per discharge calculated pursuant to section 4802 for each hospital in the peer group.
4804 CALCULATION OF THE HOSPITAL SPECIFIC COST PER DISCHARGE OF INDIRECT MEDICAL EDUCATION
4804.1 The hospital specific cost per discharge of indirect medical education shall be calculated as follows:
(a) The cost per discharge adjusted for case mix shall be divided by the indirect medical education factor set forth in subsection 4802.5.
(b) The amount established pursuant to subsection 4804.1(a) shall be subtracted from the average cost per discharge adjusted for case mix.
4805 REBASING
4805.1 Effective October 1, 2012, DHCF shall evaluate the need for rebasing and adjustment of the APDRG service intensity weights subsequent to hospital audits.
4806 CALCULATION OF APDRG SERVICE INTENSITY WEIGHTS
4806.1 The service intensity weights shall be based upon the discharge data base supplied by 3M with the version 26 APDRG grouper and centered for participating District of Columbia hospitals.
4806.2 The average charge per discharge shall be determined by identifying the average charge for cases within each discharge category, excluding outliers.
4806.3 The service intensity weight for each claim shall be equal to the ratio of the average charge per discharge for each APDRG to the aggregate average charge per discharge.
4806.4 The amount calculated in subsection 4806.3 shall be adjusted by a common factor to achieve a District wide case mix of one point zero (1.0) for the base year.
4806.5 The service intensity weights shall be modified periodically as the 3M APDRG weights are updated and new grouper versions are adopted.
4807 CALCULATION OF ADD-ON PAYMENTS
4807.1 The final base payment rate calculated pursuant to section 4801 shall be supplemented by additional payments for capital costs and direct medical education, as appropriate.
4807.2 Effective October 1, 2012, the capital cost add-on payment shall be calculated by dividing Medicaid capital costs applicable to hospital inpatient routine services costs, as reported on cost report Form HCFA 2552-10, Worksheet D, Part I, Line 200, Columns 1 and 3, or its successor, and capital costs applicable to hospital inpatient ancillary services, as determined pursuant to subsection 4807.3, by the number of Medicaid discharges in the base year.
4807.3 Capital costs applicable to hospital inpatient ancillary services, as reported on Worksheet D, Part II, Column 2, shall be allocated to inpatient capital by applying the facility ratio of ancillary inpatient charges to total ancillary charges for each ancillary line on the cost report.
4807.4 Direct medical education add-on shall be calculated by dividing the Medicaid direct medical education costs by the number of Medicaid discharges in the base year.
4807.5 Effective October 1, 2012, and annually thereafter, the base year payment rate for capital costs and direct medical education add-on payments for each participating hospital shall be based on costs from each hospital’s submitted or audited cost report for the fiscal year that ends prior to October 1 of the prior calendar year.
4807.6 If after an audit of the hospital’s cost report for the base year period an adjustment is made to the hospital’s reported costs which results in an increase or decrease of five percent (5%) or greater of the capital cost or direct medical education add-on payment, the add-on payment for capital or direct medical education add-on costs shall be adjusted.
4808 CALCULATION OF OUTLIER PAYMENTS
4808.1 The APDRG prospective payment system shall provide for an additional payment for outliers based on inpatient costs. High-cost outliers are cases with costs exceeding two point five (2.5) times the standard deviation from the mean for each APDRG classification. When the cost of a case exceeds the high-cost outlier threshold, the payment for the case shall be the sum of the base payment as described in subsection 4800.3 and the outlier payment calculated pursuant to subsection 4808.2. Effective October 1, 2012 and annually thereafter, thresholds shall be adjusted for inflation, based upon the CMS market basket factor for hospitals.
4808.2 Each claim with a cost that exceeds the high-cost outlier threshold shall be subject to an outlier payment. The amount of the outlier payment shall be calculated pursuant to the following formula:
[High cost outlier threshold minus (allowed charges X hospital cost to charge ratio)] X 0.80 or other multiplier that results in an estimated maximum of 5% of inpatient payments as high cost outliers. This factor shall be set October 1, 2012, and annually thereafter, based upon a review of claims history from the previous fiscal year.
4808.3 The cost to charge ratio shall be hospital-specific. Effective October 1, 2012, and annually thereafter, the cost to charge ratio shall be developed based upon information obtained from each hospital’s prior year submitted cost report for the fiscal year that ends prior to October 1 of the prior calendar year.
4808.4 The APDRG prospective payment system shall provide for an adjustment to payments for extremely-low-cost inpatient cases. Low-cost outliers are cases with costs less than twenty-five percent (25%) of the average cost of a case. Each claim with a cost that is less than the low-cost outlier threshold shall be subject to a partial DRG payment. The amount of the payment shall be the lesser of the APDRG amount and a prorated payment, based on the ratio of covered days to the average length of stay associated with the APDRG category. Effective October 1, 2012, and annually thereafter, the threshold shall be adjusted for inflation based upon the CMS market basket factor for hospitals.
4808.5 The prorated payment shall be calculated as follows:
(a) The base APDRG payment (Base payment times the APDRG service intensity weight) shall be divided by the average length of stay.
(b) The amount established in subsection 4808.5(a) shall be multiplied by the sum of the number of covered days plus one (1) day.
4808.6 For those APDRG categories where there was insufficient data to calculate a reliable mean or standard deviation the outlier threshold shall be calculated using an alternate method as set forth below:
(a) The outlier threshold shall be equal to the product of the weight of the APDRG and the average outlier multiplier.
(b) The average outlier multiplier shall be determined by dividing the outlier threshold by the APDRG weight for all categories where the outlier threshold is calculated as two point five (2.5) standard deviations above the mean.
4809 TRANSFER CASES AND ABBREVIATED STAYS
4809.1 For each claim involving a transfer, DHCF shall pay the transferring hospital the lesser of the APDRG amount or prorated payment based on the ratio of covered days to the average length of stay associated with the APDRG category. The prorated payment shall be calculated pursuant to the formula set forth in subsection 4808.5.
4809.2 The hospital from which the patient is ultimately discharged shall receive a payment equal to the total APDRG payment.
4809.3 All transfers except for documented emergency cases shall be authorized and approved by DHCF before the transfer as a condition of payment.
4809.4 Same day discharges shall not be paid as inpatient hospital stays unless the patient’s discharge status is death.
4810 PAYMENT TO OTHER HOSPITALS FOR INPATIENT HOSPITAL SERVICES
4810.1 The Hospital for Sick Children, Washington Specialty-Hadley Memorial Hospital, Washington Specialty-Capitol Hill, and National Rehabilitation Hospital shall be reimbursed on a per diem basis subject to the TEFRA Target Rate.
4810.2 St. Elizabeths Hospital shall be reimbursed on a per diem basis and shall not be paid more than the sum of its charges for inpatient and in-and-out surgery services to Medicaid patients in any hospital fiscal year.
4810.3 The Psychiatric Institute of Washington shall be reimbursed on a per diem basis. The per diem rate shall be calculated as follows:
(a) The base year for purposes of reimbursement shall be the District’s FY 2007;
(b) Inlier claims paid by DHCF for children in the District’s FY 2007 shall be priced pursuant to the Inpatient Psychiatric Facility Prospective Payment System PC PRICER as described and in accordance with the requirements set forth in Section 124 (c) of the Medicare, Medicaid and SCHIP Balanced Budget Refinement Act of 1999, approved November 29, 1999 (113 Stat.1501; 42 U.S.C. § 1395ww(s));
(c) The inlier claims paid by DHCF for children shall be used to develop the reimbursement rates for all beneficiaries, including those age sixty-five (65) and above; and
(d) For each claim an average per diem shall be calculated by dividing the output of the pricer by the length of stay on the claim. The average per diems shall be summed and divided by the total number of claims to determine the final per diem rate.
4811 COST REPORTING AND RECORD MAINTENANCE
4811.1 Each hospital shall submit an annual cost report to DHCF within one hundred fifty (150) days after the close of the hospital’s cost reporting period. Each cost report shall cover a twelve (12) month cost reporting period, which shall be the same as the hospital’s fiscal year, unless DHCF has approved an exception.
4811.2 Upon written request, the DHCF Director may grant a provider additional time to submit a cost report if the provider is unable to complete and submit its cost report when due as a result of circumstances beyond the provider’s control.
4811.3 Each hospital shall complete its cost report in accordance with DHCF instructions and forms and shall include any supporting documentation required by DHCF. DHCF shall review the cost report for completeness, accuracy, compliance, and reasonableness through a desk audit.
4811.4 The submission of an incomplete cost report shall be treated as a failure to file a cost report as required by subsection 4811.1, and the hospital shall be so notified.
4811.5 DHCF shall issue a delinquency notice to the hospital if the hospital does not submit its cost report when due or when the hospital is notified pursuant to subsection 4811.3 that its submitted cost report is incomplete.
4811.6 If the hospital does not submit a complete cost report within thirty (30) days after the date of the notice of delinquency, an amount equal to seventy-five percent (75%) of the hospital’s payment for the month that cost report was due shall be withheld each month until the cost report is received.
4811.7 DHCF shall pay the withheld funds promptly after receipt of the completed cost report and documentation that meets the requirements of this section.
4811.8 Each hospital shall maintain sufficient financial records and statistical data for proper determination of allowable costs.
4811.9 Each hospital’s accounting and related records, including the general ledger and books of original entry, and all transaction documents and statistical data, are permanent records and shall be retained for a period of not less than five (5) years after the filing of a cost report or until the Notice of Final Program Reimbursement is received, whichever is later.
4811.10 If the records relate to a cost reporting period under audit or appeal, records shall be retained until the audit or appeal is completed.
4811.11 Payments made to related organizations and the reason for each payment to related organizations shall be disclosed by the hospital.
4811.12 Each hospital shall:
(a) Use the accrual method of accounting; and
(b) Prepare the cost report according to generally accepted accounting principles and all Medicaid Program instructions.
4812 AUDITING AND ACCESS TO RECORDS
4812.1 DHCF, or its authorized agents, reserves the right to conduct an audit at any time upon reasonable notice to the provider.
4812.2 Each hospital shall allow appropriate DHCF auditors and authorized agents of the District of Columbia government and the United States Department of Health and Human Services access to financial records and statistical data necessary to verify costs and other data reported to DHCF.
4813 APPEALS FOR HOSPITALS THAT ARE NOT COMPENSATED ON AN APDRG BASIS
4813.1 A hospital that is not compensated on an APDRG basis shall receive a Notice of Program Reimbursement (NPR) at the end of its fiscal year after a site audit.
4813.2 Within sixty (60) days after the date of the NPR, a hospital that disagrees with the NPR shall submit a written request for an administrative review of the NPR to the Agency Fiscal Officer, Audit and Finance, DHCF.
4813.3 The written request for administrative review shall include a specific description of the audit adjustment or estimated budget item to be reviewed, the reason for the request for review of the adjustment or item, the relief requested, and documentation in support of the relief requested.
4813.4 DHCF shall mail a written determination relative to the administrative review to the hospital no later than one hundred twenty (120) days after the date of receipt of the hospital’s written request for administrative review.
4813.5 Within forty-five (45) days after receipt of DHCF’s written determination, the hospital may appeal the written determination by filing a written notice of appeal with the Office of Administrative Hearings.
4813.6 Filing an appeal with the Office of Administrative Hearings shall not stay any action to recover any overpayment to the hospital. The hospital shall be liable immediately to DHCF for any overpayment set forth in the DHCF’s determination.
4814 APPEALS FOR HOSPITALS THAT ARE COMPENSATED ON AN APDRG BASIS
4814.1 Hospitals that are compensated on an APDRG discharge basis shall receive a Remittance Advice each payment cycle.
4814.2 Within sixty (60) days after the date of the Remittance Advice, any hospital that disagrees with the payment rate calculation for the amounts listed in subsection 4814.3 or the APDRG assignment shall submit a written request for administrative review to the Agency Fiscal Officer, Audit and Finance, DHCF.
4814.3 The amounts subject to an administrative review are as follows:
(a) Add-on payment for capital costs or direct medical education costs; and
(b) Outlier payment.
4814.4 DHCF shall mail a written determination relative to the administrative review to the hospital no later than one hundred twenty (120) days after the date of receipt of the hospital's written request for administrative review under subsection 4814.2.
4814.5 Within forty-five (45) days after receipt of DHCF’s written determination, the hospital may appeal the written determination by filing a written notice of appeal with the Office of Administrative Hearings.
4814.6 Filing an appeal with the Office of Administrative Hearings shall not stay an action to recover an overpayment to the hospital.
4815 APPEAL OF ADJUSTMENTS TO THE SPECIFIC HOSPITAL COST PER DISCHARGE OR ADD-ON PAYMENTS
4815.1 After completion of a review or audit of the hospital’s cost report for the base year, DHCF shall provide the hospital a written notice of its determination of any adjustment to the Hospital’s Specific cost per discharge, direct medical education add-on payment or capital add-on payment for the base year. The notice shall include the following:
(a) A description of the rate adjustment, including the amount of the old payment rate and the revised payment rate;
(b) The effective date of the change in the payment rate;
(c) A summary of all audit adjustments made to reported costs, including an explanation, by appropriate reference to law, rules, or program manual of the reason in support of the adjustment; and
(d) A statement informing the hospital of the right to request an administrative review within sixty (60) days after the date of the determination.
4815.2 A hospital that disagrees with an audit adjustment or payment rate calculation for the Hospital Specific cost per discharge, capital add-on, or graduate medical education add-on costs shall submit a written request for administrative review to the Agency Fiscal Officer, Audit and Finance Office, DHCF.
4815.3 The written request for the administrative review shall include a specific description of the audit adjustment or payment rate calculation to be reviewed, the reason for review of each item, the relief requested, and documentation to support the relief requested.
4815.4 DHCF shall mail a formal response of its determination to the hospital not later than one hundred twenty (120) days after the date of the hospital’s written request for administrative review.
4815.5 Within forty-five (45) days after receipt of the DHCF’s written determination, the hospital may appeal the written determination by filing a written notice of appeal with the Office of Administrative Hearings.
4815.6 Filing an appeal with the Office of Administrative Hearings shall not stay any action to adjust the hospital’s payment rate.
4899 DEFINITIONS
4899.1 For the purposes of this chapter, the following terms shall have the meanings ascribed:
Base year – the standardized year on which rates for all hospitals for inpatient hospital services are calculated to derive a prospective reimbursement rate.
Department of Health Care Finance - the executive agency of the District government responsible for administering the Medicaid program within the District of Columbia effective October 1, 2008.
Diagnosis Related Group (DRG) - a patient classification system that reflects clinically cohesive groupings of inpatient hospitalizations utilizing similar hospital resources.
Direct Medical Education Costs- the total direct medical education (DME) amount on line 25 of schedule E-4 (or its successor) of the Medicare cost report divided by total inpatient days (including nursery days) multiplied by the number of Medicaid days (including nursery days). Costs shall be determined consistent with Medicare per resident amounts and capped residency counts.
High-cost outliers- claims with costs exceeding two point five (2.5) standard deviations from the mean Medicaid cost for each APDRG classification.
Low-cost outliers- claims with costs less than twenty-five percent (25%) of the average cost for each APDRG classification.
Service intensity weights - A numerical value which reflects the relative resource requirements for the DRG to which it is assigned.
TEFRA Target Rate – The rate ceiling for hospitals that are not reimbursed on a prospective payment system.
