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.