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 for information on calculating payment amounts
for transfers.
3.1.4 Calculation
of Outlier Payments. Refer to
Section 8 for
information on calculating outlier payments.
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.