2.2 Services
or Supplies Specifically Excluded from Payment
2.2.1 Non-Covered DRGs
The contractor must ensure that TRICARE coverage
requirements are met.
2.2.2 Services and Supplies Not
Related to the Treatment Regimen
Charges
for services and supplies specifically excluded from TRICARE payment
and which are not related to the treatment regimen (e.g., private
room accommodation differential if the private room was not medically
necessary and was requested by the beneficiary, or television/telephone charges)
will be the responsibility of the beneficiary. The contractor is
not to reduce the DRG-based allowance for these items, since the
DRG-based payment is the same whether or not the items are provided.
However, the hospital is permitted to bill the beneficiary for the
items.
2.3 Hospital
Days Beyond that Deemed Medically Necessary
Under
the TRICARE DRG-based payment system, the DRG amount is considered
full payment for any hospital stay, regardless of length. If any
days of a stay are subsequently determined to be medically unnecessary,
the following actions are to be taken:
2.3.1 Medically unnecessary days
which are the hospital’s responsibility. If it is determined that certain
days of care were medically unnecessary and the days are the fault
of the hospital--that is, the hospital/physician made no attempt
to discharge the patient--the unnecessary days shall be included in
the DRG-based amount, and no additional payment can be made. Nor
is the contractor to recoup any amount. However, if elimination
of the unnecessary days causes the stay to become a short-stay outlier, the
contractor is to recoup any excess amounts over the appropriate
short-stay outlier payment.
2.3.2 Medically unnecessary days
which are the beneficiary’s responsibility. If medically unnecessary
days of care were provided at the insistence of the beneficiary
(or sponsor)--that is, the hospital/physician attempted to discharge
the beneficiary, but the beneficiary insisted on remaining in the
hospital--any charges for those days will be the responsibility
of the beneficiary. This applies to all such days, and to the difference
between the normal DRG-based payment and the short-stay outlier payment
if it is determined the stay should have been a short-stay outlier.