2.2 Services or Supplies Specifically
Excluded from Payment
2.2.1 Non-Covered DRGs
The contractor shall ensure
that TRICARE coverage requirements are met.
2.2.2 Services and Supplies Not Related
to the Treatment Regimen
Charges
for services and supplies specifically excluded from TRICARE payment
and which are not related to the treatment regimen (e.g., private
room accommodation differential if the private room was not medically
necessary and was requested by the beneficiary, or television/telephone
charges) are the responsibility of
the beneficiary. The contractor shall not reduce
the DRG-based allowance for these items, since the DRG-based payment
is the same whether or not the items are provided. However, the
hospital may bill the beneficiary for
the items.
2.3 Hospital
Days Beyond that Deemed Medically Necessary
Under the TRICARE DRG-based
payment system, the DRG amount is full
payment for any hospital stay, regardless of length. If any days
of a stay are subsequently determined medically
unnecessary, the following actions are taken:
2.3.1 Medically unnecessary days that are
the hospital’s responsibility. If it is determined that certain
days of care were medically unnecessary and the days are the fault
of the hospital--that is, the hospital/physician made no attempt
to discharge the patient--the unnecessary days are included
in the DRG-based amount, and no additional payment can be made. The
contractor shall not recoup any amount.
However, if elimination of the unnecessary days causes the stay
to become a short-stay outlier, the contractor shall recoup
any excess amounts over the appropriate short-stay outlier payment.
2.3.2 Medically unnecessary days that are
the beneficiary’s responsibility. If medically unnecessary days
of care were provided at the insistence of the beneficiary (or sponsor)--that
is, the hospital/physician attempted to discharge the beneficiary,
but the beneficiary insisted on remaining in the hospital--any charges
for those days are the responsibility
of the beneficiary. This applies to all such days, and to the difference
between the normal DRG-based payment and the short-stay outlier payment
if it is determined the stay was a
short-stay outlier.