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 is 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
the
RTC submits the DHA Form 771 to the TRICARE Quality
Monitoring Contractor (TQMC),
the TQMC
shall,
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
shall return
the rate to the requesting contractor via secured means and provide
the rate to the Government for posting on
https://health.mil.
The
requesting contractor shall acknowledge receipt of the
calculated rate
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 is 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 percent 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)
are reviewed to
make sure the submitted information is complete and correctly formatted.
The data contained in these sections
is used
to figure the RTC’s prospective all-inclusive per diem rate and
is 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 percent of
total patient days, it is advisable for the reviewer to request
copies of these contracts
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
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
shall 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).
• 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 upon 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
upon 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 for the past three fiscal years:
RTC Capped
Amounts
|
Dates Of Service
|
Capped Amounts
|
|
October
1, 2019
|
- September 30, 2020
|
997
|
|
|
October 1, 2020
|
- September 30, 2021
|
1021
|
|
|
October 1, 2021
|
- September 30,
2022
|
1049
|
|
4.2.2 The 70th
percentile of the day-weighted current (
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 Consumer
Price Index - Urban (Wage Earner) (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
FY. 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 upon 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
FYs after
FY 1997, the individual facility rates and cap amount
is 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 percent 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 payer over
a facility’s base period.
6.2.3 Patient
days are combined in those situations
where third-party payers are paying
the same rate for RTC care. This
represents 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 percent 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 is
$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 is
$288 (refer
to table above).
6.3 The above
methodology for deriving the rate at 33-1/3 of the total patient
days
are only
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 are 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 percent 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)
are added
to the facility rate prior to establishing the rate derived at 33-1/3
percent 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 is
$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
are also
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
the TRICARE
Program?
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 is
$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
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
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 FY 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
|
|