1.0 DATA
COLLECTION FORM
1.1 The Defense Health Agency (DHA) Form
771 is designed for the collection of reimbursement data used in
the calculation of prospective all-inclusive per diem rates for
RTCs seeking certification under the TRICARE RTC program. The form
will be sent out as part of the RTC certification package encouraging
the facility to conduct a preliminary review of the reimbursement
methodology prior to completion of the program certification portion
of the application. Refer to attached DHA Form
771.
1.2 After
submission of the DHA Form 771 to the TRICARE Quality Monitoring
Contractor (TQMC), contractors should anticipate that the TQMC will,
if needed, contact the facility, assist with gathering any additional
information needed and calculate the initial per diem RTC reimbursement
rate. When the rate is calculated, the TQMC will return the rate
to the requesting contractor via secured means and provide the rate
to the Government for posting on
https://health.mil.
Receipt of the calculated rate should be acknowledged to the TQMC
at the address provided by the Contracting Officer Representative
(COR) or the TQMC. The rate calculation process will begin with
the contractor’s submission of DHA Form 771 to the TQMC. A complete
or substantially complete DHA Form 771 will expedite the rate calculation
process.
1.3 If
an RTC requests an initial per diem reimbursement rate calculation
before submitting a request for TRICARE participation, the RTC should
be referred by the contractor to this chapter. An RTC shall use
this guidance to determine the approximate rate.
1.4 The
DHA Form 771
is divided into two distinct data collection areas, one dealing
with administrative information and the other with reimbursement
information.
1.4.1 Administrative
Information. Items 1 through 8 of the form identify the facility
and establish the base year period over which the reimbursement
data was collected. The Employer Identification Number (EIN) is
of particular importance since it identifies the RTC for payment.
1.4.2 Reimbursement Information. Items
9 through 11 provide the reimbursement data necessary to calculate
an all-inclusive prospective per diem rate for applying RTCs. The
data represents those reimbursement levels that the RTC was willing
to accept from other third-party payers during its base period.
This allows the establishment of a per diem rate which reflects
a reasonable amount consistent with rates charged by its peers nationally
and with reimbursement it is accepting from other third-party payers.
2.0 Administrative
Support
2.1 The reviewer will provide the name and telephone
number of a contact person that can provide additional help and
instruction in filling out the data request form.
2.2 Examples
of rate calculations are useful in establishing a conceptual understanding
of the per diem methodology and for allowing the RTC to approximate
its rates. These examples should include, but not be limited to,
the following reimbursement concepts/issues:
• 33-1/3% rule.
• All-inclusive rate.
• Charges allowed
outside all-inclusive rate.
• Rate updates.
• Open vs. closed
staffing models.
3.0 REVIEW
AND ANALYSIS OF SUBMITTED INFORMATION
3.1 Conduct a preliminary review
of the information/data submitted on the
DHA Form
771 paying particular attention to the opening and data collection
start dates. The data collection start date for RTCs which were
in operation during the entire base period (July 1, 1987 - June
30, 1988) will be July 1, 1987. The data collection start date
will be
the same as the opening date for facilities who began operation
after June 30, 1988, or began operation before July 1, 1988, but
had less than six months of operation by July 1, 1988, since the
RTC’s base period
will be its first
12 months of operation. If the dates are not the same, follow the
guidelines below:
3.1.1 Contact the person designated in Item #4 of DHA Form
771 for clarification regarding the discrepancy.
3.1.2 If the
discrepancy resulted from a transcription error, correct the error
and proceed with the review.
3.1.3 If the discrepancy did not result
from a transcription error, have the RTC submit revised data encompassing
the correct data collection period (i.e., data collected over the
first 12 months of operation).
3.2 The reimbursement sections
(Items 9 through 10)
will be reviewed
to make sure the submitted information is complete and correctly
formatted. The data contained in these sections will be used to figure
the RTC’s prospective all-inclusive per diem rate and will be the
basis for all future rates. The following are the data element requirements
under each of these sections:
3.2.1 Item #9. This
section requests information on all third-party payers establishing
or affecting an RTC’s rates during its specified base period. It
includes the following reimbursement information:
3.2.1.1 Name, address
and telephone number of each payer for whom a rate was established/accepted.
This information is important for verification of rates under Items
9 through 11, especially in the case of state patients where there
is often a negotiated contract. If the state rate represents 33-1/3%
of total patient days, it is advisable
for the reviewer to request copies of these contracts in order to verify
the negotiated rates in effect during the RTCs base period. However,
the reviewer will be given discretion in setting its own review
parameters for requesting supporting documentation.
3.2.1.2 The rates
accepted from each third-party payer during the RTC’s designated
base period. The accepted rates should not be confused with actual
charged amounts. It is not uncommon to bill third-party payers amounts
in excess of their allowed charges knowing payment will be less
than the charged amounts. The allowed charge represents the amount
the facility is willing to accept from a
payer for
RTC care. A determination will be made whether the listed facility
rates represent total daily charges (i.e., represent an all-inclusive
rate) or only the institutional component of the accepted rate using
the following guidelines:
3.2.1.2.1 If there
are no additional charges listed under Item #10, the facility rates
appearing in Item #9 will be determined
as all-inclusive, and as such, represent payment in full for all
mental health services provided within the RTC (both professional
and institutional).
3.2.1.2.2 If additional
charges are listed under Item #10, a determination will be
made on whether they apply to all of the third-party payers appearing
in Item #9; i.e., whether all of the third-party payers allow payment
of additional services above the facility rates listed in Item #9.
The reviewer will note that where state
or local agencies are involved most of their reimbursement is based upon flat per
diem rates. The reviewer will contact
the RTC if there is any question regarding the applicability of Item
#10 charges to any one of the listed third-party payers.
3.2.1.3 The number
of patient days provided/paid at each accepted rate. Cumulative
patient days will be used in determining the rate high enough to
cover at least one-third of the total patient days subject to the
cap amount.
3.2.2 Item #10. This
section requests information on the payment of any additional services allowed
outside the facility rates recorded under Item #9. The sum of these
charges will be added to the facility rate in calculating the TRICARE
all-inclusive per diem rate. The RTC
shall provide
the methodology (the actual calculations) used in establishing the
charge Per Patient Day (PPD) for each of the services listed in
this section.
3.2.2.1 Required data elements:
• The service for which
additional payment is allowed.
• The frequency of
the service.
• The
accepted charge/rate per service.
• The accepted charge/rate
PPD.
3.2.2.2 The following
are examples of services which
may be
allowed for payment outside the facility rates reflected in Item
#9:
• Admission
history and physical.
• Medical visits
for physical illness or injury.
• Lab drug testing.
• EKG.
• Family therapy.
• Pharmaceuticals.
• Individual and
group psychotherapy.
3.2.3 Item
#11. This section pertains to the payment of educational
services in an RTC. Educational charges are excluded from payment
under the prospective per diem system. If the RTC indicates that
educational charges are included within the facility rate, they
will be
removed prior to establishing the TRICARE all-inclusive rate. The
educational rate/charge per patient per day reported in Item #11.b
will be subtracted from the overall facility rate.
Educational
services
shall be paid apart from the
facility per diem
only when the services
have been authorized by the reviewer. The RTC may provide educational
services to its children under the following arrangements:
• The
RTC has its own educational program whereby it bills for the entire
educational component, incorporating facility and professional costs
(i.e., bills for teachers, books, supplies, classroom facilities,
etc.).
• The
RTC has an agreement with its local school district to share in
the education of its children. In most cases the local school district
agrees to supply the teachers while the RTC provides the classrooms.
The RTC only bills for the facilities charges.
• The local school district
accepts total responsibility for educating the RTC children. No educational
charges are billed since the children attend public school during
the day.
3.3 The data collected and used
to establish RTC per diem rates will be retained indefinitely.
4.0 BASE
YEAR CALCULATIONS
4.1 For RTCs new to the TRICARE program, one of
the following two alternative methods will be used in determining
their individual rates:
4.1.1 The
rates for an RTC which was in operation during the base period (July
1, 1987 through June 30, 1988) will be calculated based on the actual
charging practices of the RTC during the 12 months ending July 1,
1988. The individual RTC rate will be the lower of either the TRICARE
rate in effect on June 30, 1988, or the rate high enough to cover
at least one-third of the total patient days of care provided by
the RTC during the 12 months ending July 1, 1988 subject to a maximum
cap.
4.1.2 The rates for an RTC which began operation
after June 30, 1988, or began operation before July 1, 1988, but
had less than six months of operation by July 1, 1988, will be based
on the actual charging practices during its first six to 12 consecutive
months, with six months being the minimum time in operation for
authorization under
the TRICARE program. A period of less than 12 months will be used
only when the RTC has been in operation for less than 12 months.
Once a full 12 months is available, the rate
will be
recalculated using the additional reimbursement data. The rates
will be calculated
the same as in
paragraph 4.1.1, except a different base period
will be
used.
4.2 The following methods are
used in establishing the maximum capped per diem amounts:
4.2.1 Prior
to April 6, 1995, the capped per diem amount was set at the 75th
percentile of all established TRICARE RTC rates nationally and weighted
by total TRICARE days provided at each rate during the base period
(July 1, 1987, through June 30, 1988). The capped amount was adjusted annually
by the designated update factor (currently the Medicare update factor
as noted in
Chapter 7, Section 1). The following are the
capped amounts in effect since December 1, 1988:
RTC Capped Amounts
|
Dates
Of Service
|
Capped
Amounts
|
|
October 1, 2013
|
- September 30,
2014
|
843
|
|
|
October 1, 2014
|
- September 30,
2015
|
868
|
|
|
October 1, 2015
|
- September 30,
2016
|
889
|
|
|
October 1, 2016
|
- September 30,
2017
|
914
|
|
|
October
1, 2017
|
-
September 30, 2018
|
939
|
|
4.2.2 The 70th percentile of the
day-weighted current (Fiscal Year (FY) 1995) per diems was used in
establishing a new cap amount for services rendered on or after
April 6, 1995. The following methodology was used in establishing
the RTC cap and floor amounts:
4.2.2.1 RTC institutional
claims data from the period October 1, 1993 to March 31, 1994 were
used (the first half of FY 1994).
4.2.2.2 The FY
1994 per diems were merged onto the claims (from the RTC per diem
list in the TRICARE Policy Manual (TPM)) and updated by 1.046 (the
CPI-U) to represent FY 1995 per diems.
4.2.2.3 The 30th
and 70th percentiles of the day-weighted FY 1995 per diems were
calculated as $429 and $515. Any RTC per diem above $515 was cut
to $515 as of April 6, 1995.
5.0 ADJUSTMENT
OF BASE YEAR RATE
5.1 The base year rate is adjusted by the following
annual inflation factors to bring it forward to the current fiscal
year. See
Section 1, paragraph 3.5.3 for the update
factors for FY 2006 and forward.
Update Factors For RTC
Per Diem Rates
Note: The FY 1997 CPI-U for medical
care is 2.6%. This inflation will be used in adjusting FY 1995 RTC
rates falling below the 30th percentile of all established FY 1995
rates ($429.00). See also
Chapter 7, Section 1, for FY 2006 and forward.
|
|
Time
Period
|
CPI-U
Inflation Factors
|
|
July 1, 1988
|
- November 30,
1988
|
|
2.6%
|
|
December 1, 1988
|
- July 30, 1989
|
|
4.9
|
|
October 1, 1989
|
- September 30,
1990
|
|
9.2
|
|
October 1, 1990
|
- September 30,
1991
|
|
8.6
|
|
October 1, 1991
|
- September 30,
1992
|
|
7.4
|
|
October 1, 1992
|
- September 30,
1993
|
|
6.0
|
|
October 1, 1993
|
- September 30,
1994
|
|
4.6
|
|
October 1, 1994
|
- September 30,
1995
|
|
4.4
|
|
October 1, 1995
|
- September 30,
1996
|
|
3.6
|
|
Time
Period
|
Medicare
Update Factor
|
|
October 1, 1997
|
- September 30,
1998
|
|
2.4
|
|
October 1, 1998
|
- September 30,
1999
|
|
2.4
|
|
October 1, 1999
|
- September 30,
2000
|
|
2.9
|
|
October 1, 2000
|
- September 30,
2001
|
|
3.4
|
|
October 1, 2001
|
- September 30,
2002
|
|
3.3
|
|
October 1, 2002
|
- September 30,
2003
|
|
3.5
|
|
October 1, 2003
|
- September 30,
2004
|
|
3.4
|
|
October 1, 2004
|
- September 30,
2005
|
|
3.3
|
|
October 1, 2005
|
- September 30,
2006
|
|
3.8
|
5.2 If the RTC’s base year falls
within the previous year’s reporting period, the inflation factor
is prorated for the remaining time in that period. The updating
process can best be demonstrated through the following example:
Example: RTC
E is submitting reimbursement information as a final step in its authorization process.
The data was collected over the facility’s first 12 months of operation
(April 1, 2013 - March 31, 2014). Since the RTC’s base period extended
six months (or 180 days, based on 30-day months and a 360-day year)
into the inflation reporting period, the inflation factor for the
subsequent update year (October 1 - September 30) was prorated for
the remaining time period of April 1, 2014 - September 30, 2014
(six months or 180 days). The following are the calculations used
in updating the RTC’s all-inclusive base year per diem to FY 2015
(current year per diem amount):
|
Adjustment Of Base Year Per Diem Rate
|
|
Derived rate at
33.33% of total patient days during base period of April 1, 2013
through March 31, 2014.
|
$500.00
|
|
Plus:
|
|
An adjustment
for the annual update factor, as listed in Chapter 7, Section 1, paragraph 3.5.3 |
|
|
For 6-month
period ending September 30, 2014 (2.5% x 6/12 = 1.25%)
|
6.25
|
|
Adjusted
Rate
|
$506.25
|
|
|
|
|
For 12-month
period ending September 30, 2015 (2.9%)
|
14.68
|
|
Adjusted
Rate
|
$520.93
|
|
|
|
|
TRICARE
all-inclusive per diem rate for services on or after October 1,
2015
|
$521.00
|
5.3 In a Final Rule published
in the
Federal Register (60 FR 12419) on March 7, 1995,
TRICARE imposed a two-year moratorium on the annual updating of
RTC per diems rates subject to the following provisions:
5.3.1 TRICARE
payments will remain at FY 1995 rates for a two-year period beginning
in FY 1996, for any RTC whose 1995 rate was at or above the 30th
percentile of all established FY 1995 rates ($429).
5.3.2 For any
RTC whose FY 1995 rate was below that of the 30th percentile, the
rate will be adjusted by the lesser of the CPI-U, or the amount
that brings the rate up to the 30th percentile level.
5.3.3 For fiscal
years after FY 1997, the individual facility rates and cap amount
will be adjusted by the Medicare update factor for hospitals and
units exempt from the Medicare prospective payment system at the
discretion of the Director, DHA or designee.
Note: The above provisions will lead to aggregate expenditures
which approximate average facility costs. The 4.4% update factor
was used in the RTC rate computation since its FY 1995 rate ($368) was
below the 30th percentile level ($429).
6.0 CALCULATION
OF RTC PER DIEM RATE
6.1 Array the rates accepted by other third-party
payers (Item #9) in descending order from lowest to highest in the
first column of the Reimbursement Information Work Sheet (see Attachment).
6.2 Place the
number of days paid at each of the rates listed above in the second
column of the work sheet.
6.2.1 If there is more than one
rate with an individual third-party payer during the base period, the
RTC
shall provide the total number
of patient days paid by the payer at each rate. Total patient days will
be used in determining the most favored rate for the facility. The
following is an example of multiple rates paid by an individual
payer during the RTC’s base period:
Example: RTC
F has negotiated three separate rates with a third-party payer over
its base period. The three rates were reported as follows:
1. $295/day from July 2013, through October
31, 2013 - 2,000 patient days;
2. $315/day from November 1, 2013, through
February 29, 2014 - 3,000 patient days;
3. $330/day from March 1, 2014, through
June 30, 2014 - 2,000 patient days.
6.2.2 Each of
the above negotiated rates shall be
reported separately in Item #9 of the DHA Form 771
representing a blending of payments made by a particular payor over
a facility’s base period.
6.2.3 Patient days will be
combined in those situations where third-party payers were paying
the same rate for RTC care. This will represent
the cumulative frequency of payments made at each reported reimbursement
level in Item #9 of the data collection form.
6.2.4 The following
examples represent the methodology used in calculating the TRICARE
base year facility rate from data provided under Item #9 of the
DHA Form
771:
Example: RTC G provided the following third-party reimbursement
data under Item #9 of the DHA Form 771 as part of the certification
process:
Item #9 Of DHA Form
771 (Modified For Example)
|
Third-Party
Payers
|
Rate Accepted
|
Patient
Days
|
|
*** - State or local Government agency.
|
|
AA
|
$253
|
312
|
|
BB
|
527
|
207
|
|
CC
|
402
|
163
|
|
DD ***
|
212
|
198
|
|
EE
|
454
|
371
|
|
FF
|
603
|
118
|
|
GG
|
317
|
446
|
|
HH
|
489
|
538
|
|
II
|
552
|
319
|
|
JJ
|
503
|
132
|
Step 1: Array the rates in descending
order from lowest to highest with corresponding patient days paid
at each rate:
|
(1)
Rates
|
(2)
Patient
Days
|
(3)
Cumulative
Patient Days
|
(4)
Percent Cumulative Patient Days
|
|
$212
|
|
198
|
|
198
|
|
7.1
|
%
|
|
253
|
|
312
|
|
510
|
|
18.2
|
|
|
317
|
|
446
|
|
956
|
|
34.1
|
|
|
402
|
|
163
|
|
1,119
|
|
39.9
|
|
|
454
|
|
371
|
|
1,490
|
|
53.1
|
|
|
489
|
|
538
|
|
2,028
|
|
72.3
|
|
|
503
|
|
132
|
|
2,160
|
|
77.0
|
|
|
527
|
|
207
|
|
2,367
|
|
84.4
|
|
|
552
|
|
319
|
|
2,686
|
|
95.8
|
|
|
603
|
|
118
|
|
2,804
|
|
100.0
|
|
|
|
|
Total
|
2,804
Patient Days
|
Step 2: Sum the patient days in
column 2, which in this particular example equals 2,804 patient days.
Step 3: Calculate
33-1/3% of the total patient days by multiplying total patient days
figured in Step 2 by 0.3333.
(2,804 patient
days x 0.3333 = 934.57 patient days)
Step 4: Go
down in the cumulative patient day column (column 3) to where 33-1/3%
of the patient days lie (934.57).
Step 5: Go
across to the rate in column 1 in which 33-1/3 of the cumulative
patient days fall. This represents the base year/period facility
rate. The base year/period rate in this example would be $317 (refer
to table above).
Example: RTC H provided the following
third-party reimbursement data under Item #9 of the DHA Form 771
as part of the certification process:
Item #9 Of DHA Form
771 (Modified For Example)
|
Third-Party
Payers
|
Rate
Accepted
|
Patient
Days
|
|
*** - State or local Government agency.
|
|
AA
|
$425
|
|
201
|
|
|
BB ***
|
288
|
|
600
|
|
|
CC ***
|
235
|
|
63
|
|
|
DD ***
|
215
|
|
1,040
|
|
|
EE
|
365
|
|
276
|
|
|
FF
|
515
|
|
168
|
|
|
GG ***
|
288
|
|
346
|
|
|
HH
|
489
|
|
538
|
|
|
II
|
425
|
|
319
|
|
|
JJ
|
450
|
|
132
|
|
Step 1: Array the rates in descending
order from lowest to highest with corresponding patient days paid
at each rate:
|
(1)
Rates
|
(2)
Patient
Days
|
(3)
Cumulative
Patient Days
|
(4)
Percent Cumulative Patient Days
|
|
$215
|
|
1,040
|
|
1,040
|
|
28.2
|
%
|
|
235
|
|
63
|
|
1,103
|
|
29.9
|
|
|
288
|
|
946
|
|
2,049
|
|
55.6
|
|
|
365
|
|
276
|
|
2,325
|
|
63.1
|
|
|
425
|
|
520
|
|
2,845
|
|
77.2
|
|
|
450
|
|
132
|
|
2,977
|
|
80.8
|
|
|
489
|
|
538
|
|
3,515
|
|
95.4
|
|
|
515
|
|
168
|
|
3,683
|
|
100.0
|
|
|
|
|
Total
|
3,683
Patient Days
|
Step 2: Sum
the patient days in column 2, which in this particular example equals 3,683 patient
days.
Step 3: Calculate 33-1/3% of the total patient days
by multiplying total patient days figured in Step 2 by 0.3333.
(3,683 patient days x 0.3333 = 1,227.54 patient
days)
Step 4: Go down in the cumulative
patient day column (column 3) to where 33-1/3% of the patient days
lie (1,227.54).
Step 5: Go across to the rate in
column 1 in which 33-1/3 of the cumulative patient days fall. This
represents the base year/period facility rate. The base year/period
rate in this example would be $288 (refer to table
above).
6.3 The above methodology for
deriving the rate at 33-1/3 of the total patient days
will only
be applicable under the following conditions:
6.3.1 If the rates in Item #9 were
all-inclusive for payment of RTC care (i.e., included all payments for
institutional and professional services), no additional charges will be
added on to the facility rates from Item #10 of the data collection
form. The rate established in Step 5 of the above examples will represent
the all-inclusive base year rate prior to the inflationary adjustment.
6.3.2 If the
charges for additional services listed in Item #10 applied to all
of the third-party payers identified in Item #9 (i.e., all of the
third-party payers listed in Item #9 allowed payment for additional
services outside the facility rate- rate derived at 33-1/3% of total
RTC patient days during the base period-- at the charges PPD established
in Item #10), the sum of these charges are added to the facility
rate prior to inflationary adjustment.
6.4 In cases
where payment of additional services listed in Item #10 do not apply
to all of the third-party payers listed in Item #9, or payments
vary among the payers for the same services, the sum of the charges
PPD for additional services (reported in the last column of Item
#10)
will be added to the facility
rate prior to establishing the rate derived at 33-1/3% of the total
patient days. The following example provides the methodology for
incorporating these additional charges into the base year rate computations:
Example: RTC
I has provided a revised DHA Form 771 indicating that payments for
additional services had been overlooked in completing its initial
form. The following service charges PPD were provided under Item
#10 with the proviso that the additional payments were not allowed
by the three state agencies and two private third-party providers.
The payers were identified in Item #9 of the form.
Item #10 Of DHA Form
771 (Modified For Example)
|
Patient Service
|
Frequency
Of Service
|
Charge Per Service
|
Charge Per Day (PPD)
|
|
Individual Therapy
|
1/week
|
$120.00
|
|
$17.14
|
|
|
Group Therapy
|
2/week
|
45.00
|
|
12.86
|
|
|
Admission History
and Physical
|
1/stay
|
150.00
|
|
1.43
|
|
|
Pharmacy
|
($10,438/2,498
days)
|
|
|
4.18
|
|
|
Psych. Testing
|
28
|
650.00
|
|
7.29
|
|
|
|
|
|
|
Total
$42.90
|
|
Note: The RTC’s Average
Length-Of-Stay (ALOS) was 105 days during its base period.
Item #9 Of DHA Form
771 (Modified For Example)
|
Third-Party
Payers
|
Rate Accepted
|
Patient
Days
|
|
** - State or local Government agency.
*** - Rates represent entire payment
for RTC services. Charges for additional services reported in Item
#10 not applied to these designated third-party payer rates.
|
|
AA
|
$383
|
114
|
|
BB **
|
165 ***
|
313
|
|
CC **
|
268
|
102
|
|
DD **
|
204 ***
|
485
|
|
EE
|
365
|
232
|
|
FF
|
471 ***
|
117
|
|
GG **
|
265 ***
|
346
|
|
HH
|
489
|
338
|
|
II
|
425 ***
|
319
|
|
JJ
|
425
|
132
|
|
(1)
Rates
|
(2)
Additional Payments
|
(3)
Patient
Days
|
(4)
Cumulative
Patient Days
|
(5)
Percent Cumulative Patient Days
|
|
$165
|
|
$N.A.
|
313
|
|
313
|
|
12.5
|
%
|
|
204
|
|
N.A.
|
485
|
|
798
|
|
31.9
|
|
|
265
|
|
N.A.
|
346
|
|
1,144
|
|
45.8
|
|
|
268
|
|
42.90
|
102
|
|
1,246
|
|
49.9
|
|
|
365
|
|
42.90
|
232
|
|
1,478
|
|
59.2
|
|
|
425
|
|
N.A.
|
319
|
|
1,797
|
|
71.9
|
|
|
383
|
|
42.90
|
114
|
|
1,911
|
|
76.5
|
|
|
425
|
|
42.90
|
132
|
|
2,043
|
|
81.8
|
|
|
471
|
|
N.A.
|
117
|
|
2,160
|
|
86.5
|
|
|
489
|
|
42.90
|
338
|
|
2,498
|
|
100.0
|
|
|
|
|
Total
|
2,498
Patient Days
|
Step 1: Array the rates in descending
order from lowest to highest with corresponding patient days paid
at each rate.
Step 2: Sum the patient days in
column 3, which in this particular example equals 2,498 patient
days.
Step 3: Calculate 33-1/3% of the total patient days
by multiplying total patient days figured in Step 2 by 0.3333.
(2,498 patient days x 0.3333 = 832.58 patient
days)
Step 4: Go down in the cumulative
patient day column (column 4) to where 33-1/3% of the patient days
lie (832.48).
Step 5: Go across to the rates in
column 1 and 2 in which 33-1/3 of the accumulative patient days
fall. This represents the TRICARE all-inclusive base
year/period rate. The base year/period rate in this example would
be $265 (refer to table above).
6.5 If the
RTC answers no to Item #11.a., the educational rate/charge
PPD reported in Item #11.b will be
subtracted from the overall facility base year/period rate.
6.6 Personal
item charges
will also be subtracted
from the all-inclusive base year/period prior to inflationary adjustment.
Example: RTC
J checked no in Item #11.a. of the DHA Form 771 reporting an educational
rate/charge PPD in Item #11.b. The RTC also reported a $1 PPD charge
for personal items.
|
|
Accepted
Rate at 1/3 of Patient Day
|
$350
|
|
|
Plus:
|
|
|
|
Other Service
Charges
|
45
|
|
|
Less:
|
|
|
|
Personal
Items
|
1
|
|
|
Education
|
20
|
|
|
All-Inclusive
Base Period Rate Prior to Inflationary Adjustment
|
$374/day
|
6.7 The following is a detailed
example of an RTC per diem calculation incorporating all of the
data elements reported on the DHA Form 771 including inflationary
adjustments:
Example: RTC K submitted the following
reimbursement information as part of the certification process:
Data Review & Analysis
|
Item
|
Data Requested
|
Data Reported
|
|
2
|
EIN
|
38-1734578
|
|
5
|
Opening Date
|
June 1, 2010
|
|
6
|
Joint Commission
Accreditation
|
October 31, 2012
|
|
7
|
Data Collection
Dates
|
June 1, 2010 -
May 31, 2011
|
Item #9 Of DHA Form
771 (Modified For Example)
|
Third-Party PayErs
|
Rate
Accepted
|
Patient
Days
|
|
AA
|
$285
|
|
214
|
|
BB
|
453
|
|
102
|
|
CC
|
314
|
|
371
|
|
DD
|
388
|
|
163
|
|
EE
|
502
|
|
118
|
|
FF
|
314
|
|
246
|
|
GG
|
489
|
|
138
|
|
HH
|
402
|
|
319
|
Item #10 Of DHA Form
771 (Modified For Example)
|
Patient Service
|
Frequency Of Service
|
Charge Per Service
|
Charge Per Day (PPD)
|
|
Individual Therapy
|
1/week
|
$90.00
|
|
$12.86
|
|
|
Group Therapy
|
1/week
|
45.00
|
|
6.43
|
|
|
Family Therapy
|
1/2 weeks
|
65.00
|
|
4.64
|
|
|
Admission History
& Physical
|
1/stay
|
($175/120)
|
(ALOS)
|
1.46
|
|
|
Pharmacy
|
($5,638/1,671
days)
|
|
|
3.38
|
|
|
Psych.
Testing
|
28
|
650.00
|
|
6.28
|
|
|
|
|
|
|
Total
$35.05
|
|
Item #11.
EDUCATIONAL CHARGES:
6.7.1 Are educational charges excluded
from the daily rate when billing TRICARE?
YES
X NO ____
6.7.2 What is the educational rate/charge
per patient per day in your facility?
$37.00
PPD
BASE YEAR/PERIOD RATE CALCULATION
Step 1: Array
the rates in descending order from lowest to highest with corresponding
patient days paid at each rate:
|
(1)
Rates
|
(2)
Patient Days
|
(3)
Cumulative
Patient Days
|
(4)
Percent Cumulative
Patient Days
|
|
$285
|
|
214
|
|
214
|
|
12.8
|
%
|
|
314
|
|
617
|
|
831
|
|
49.7
|
|
|
388
|
|
163
|
|
994
|
|
59.5
|
|
|
402
|
|
319
|
|
1,313
|
|
78.6
|
|
|
453
|
|
102
|
|
1,415
|
|
84.7
|
|
|
489
|
|
138
|
|
1,553
|
|
92.9
|
|
|
502
|
|
118
|
|
1,671
|
|
100.0
|
|
|
|
|
Total
|
1,671
Patient Days
|
Step 2: Sum
the patient days in column 2, which in this particular example equals 1,671 patient
days.
Step 3: Calculate 33-1/3% of the total patient days
by multiplying total patient days figured in Step
2 by
0.3333.
(1,671 patient days x 0.3333 = 556.94
patient days)
Step 4: Go down in the cumulative
day column (column 3) to where 33-1/3% of the patient days lie (556.94).
Step 5: Go
across to the rate in column 1 in which 33-1/3 of the cumulative
patient days fall. This represents the base year/period facility rate.
The base year/period facility rate in this example would be $314 (refer
to table above).
Step 6: Add
the sum of the charges PPD reported in Item #10 of the Form 771
($35.05/patient day) to the base year/period facility rate figured
in Step
5 since additional payments are allowed for
all the listed third party payers in Item #9. The base year/period
all-inclusive per diem rate is $349.05.
Step 7: Subtract
any educational and/or personal item charges which are included
in the all-inclusive base year/period rate calculated in Step
6.
This does not apply in this particular example since there are no
personal item and/or educational charges included in the base year/period
facility rate.
INFLATIONARY ADJUSTMENTS
Step 1: Adjust
the base year rate by the annual inflation factors to bring it forward
to the current fiscal year as follows:
|
Adjustment Of Base Year Per
Diem Rate
|
|
|
Derived rate at
33.33% of total patient days during base period of June 1, 2010
- May 31, 2011.
|
$349.05
|
|
Plus:
|
|
|
Update Factors:
|
|
|
For 4-month
period ending September 30, 2011 (0.87%) (2.6% x 4/12 = 8.7%)
|
3.04
|
|
Adjusted
Rate
|
$352.09
|
|
|
|
|
For 12-month
period ending September 30, 2012 (3.0%)
|
10.56
|
|
Adjusted
Rate
|
$362.65
|
|
|
|
|
For 12-month
period ending September 30, 2013 (2.6%)
|
9.43
|
|
Adjusted
Rate
|
$372.08
|
|
|
|
|
For 12-month
period ending September 30, 2014 (2.5%)
|
9.30
|
|
Adjusted
Rate
|
$381.38
|
|
|
|
|
For 12-month
period ending September 30, 2015 (2.9%)
|
11.06
|
|
Adjusted
Rate
|
$392.44
|
|
|
|
|
TRICARE all-inclusive
per diem rate for services on or after October 1, 2015.
|
$393.00
|
|
|
|
Note: The rate is the
lessor of the calculated per diem or the capped per diem rate, as
noted in paragraph 4.2.1.
|
|
|
|
|
ATTACHMENT:
|
|
|
DHA Form
771
|
|
Figure 7.B-1 DHA Form
771
|
|