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.