3.1 Calculation
Of Payment Amounts
3.1.1 To
determine the actual payment for an individual claim (except for
short-stay outliers and transfers) under the DRG-based payment system.
The following steps shall be used to calculate the payment amount.
In performing these calculations, the contractor may either round
the amounts or simply truncate them to two decimal places when calculating
the DRG-based payment amount. (All other calculations shall not
be rounded or truncated.) The actual payment for an individual claim
for all hospitals, including children’s hospitals and neonates,
shall be calculated using Steps
1 through
5 and Steps
8 and
9.
Step 1: Determine
the DRG applicable to the claim.
Step 2: Determine
if the hospital is large urban or other.
Step 3: Multiply
the labor-related portion of the adjusted standardized amount (ASA)
and the labor-related portion of the children’s hospital differential
if the hospital is a children’s hospital by the wage index applicable
to the hospital which provided the services (this is “A”).
Step 4: Add
the nonlabor-related portion of the ASA and the nonlabor-related
portion of the children’s hospital differential if the hospital
is a children’s hospital to “A” (this is “B”).
Step 5: Multiply
“B” by the DRG weight (this is “C”).
Step 6: Determine
any cost or long-stay outlier amounts (using “C”) and add them to
“C” (this is “D”).
Step 7: Multiply “D” by one plus
the Indirect Medical Education (IDME) adjustment factor if applicable
(this is “E”).
Step 8: Multiply
“C” by one (1) plus the IDME adjustment factor if applicable (this
is “D”).
Step 9: Determine
any cost outlier payment amount as outlined in
Section 8 and
add it to “D” if the hospital is a teaching hospital, or “C” if
it is not a teaching hospital (this is “E”).
3.1.2 Calculation
of Short-Stay Outlier
Step 1: Calculate
the DRG Basic Amount as outlined in Steps
1 through
5 in
paragraph 3.1.1 (this
is “A”).
Step 2: Divide “A” by the Arithmetic
Mean Length-of-Stay (LOS) for the applicable DRG to determine the
DRG per diem rate (this is “B”).
Step 3: Multiple
“B” by the number of eligible days to determine the DRG Per Diem
Amount (this is “C”).
Step 4: Multiple “C” by the Short-Stay
Marginal Cost Factor of 2.00 to determine the Short-Stay Outlier
Basic Amount (this “D”).
Step 5: Compare
“D” to “A”, if “D” is less than “A”, multiple “D” by one (1) plus
the IDME adjustment factor if applicable, to arrive at the Short-Stay
Outlier Allowed Amount (this is “E”). If “D” is greater than “A”,
calculate the DRG payment amount as outlined in
paragraph 3.1.1.
3.1.3 Calculation
of Transfer Payment Amounts. Refer to
Section 3, paragraph 3.6 for information on
calculating payment amounts for transfers.
3.2 Data Sources
In order to calculate the DRG weights and adjusted
standardized amounts for the TRICARE DRG-based payment system for
the upcoming fiscal year, DHA will use data collected for all TRICARE hospital
claims from the previous 12 month period July 1 through June 30.
3.3 Development
Of The Database
Before calculating the DRG
weights and standardized amount, certain modifications to the database
of hospital claims will be made.
3.3.1 Records for exempt hospitals.
Since certain hospitals will be exempt from the TRICARE DRG-based
payment system (see
Section 4) and records from these hospitals
shall be deleted from the database.
3.3.2 Interim bills. The DRG payment
will be full payment for a complete hospital stay. Therefore, in
those instances where a hospital has submitted one or more interim
bills for a long LOS, the interim bills shall be deleted from the
database and only final, total bills will be used.
3.3.3 Unallowable
charges. All charges relating to services which are not included
in the DRG payment shall be removed from the database. These services
include emergency room, outpatient services, ambulance, home health
visits, professional fees, and other similar services.
3.3.4 Exempt
services. All charges related to exempt services, primarily psychiatric
and substance abuse DRGs, shall be removed from the database.
3.3.5 Combined
mother/newborn bills. During at least part of the initial database
period, hospitals were permitted to bill maternity services on a
single claim. Since the TRICARE DRG-based payment system has separate
DRGs for deliveries (the mother’s care) and for newborn care, those claims
for which the services were combined into a single charge shall
be removed from the database.
3.3.6 Record errors. All records
which contain errors of any type (e.g., the record cannot positively be
matched to a specific hospital because of an error in the provider
name or number) shall be removed from the database.