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
The contractor
shall not reduce the DRG-based allowance for 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).
These charges will be the responsibility of the beneficiary. DRG-based
payment is the same whether or not the items are provided. However,
the hospital is permitted to 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 considered
full payment for any hospital stay, regardless of length. If any
days of a stay are subsequently determined to be medically unnecessary,
the following actions are to be taken:
2.3.1 Medically
unnecessary days which 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 shall
be included in the DRG-based amount, and no additional payment can
be made. Nor is the contractor to recoup any amount.
2.3.2 The contractor shall not recoup
any excess amounts over the appropriate short-stay outlier payment unless
elimination of unnecessary days causes the stay to become a short-stay
outlier, then the contractor shall recoup any excess amounts over
the appropriate short-stay outlier payment.
2.3.3 Medically unnecessary days
which 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 will be 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 should have been a short-stay outlier.