2.4.5.2 Example:
2.4.5.2.1 COVID-19 case with a full DRG payment
of $20,000 including the 20% DRG adjustment and a billed charge
of $100,000. The TRICARE fixed-loss threshold in CY 2021 was equal
to $29,064. For this example, assume that the TRICARE inpatient
operating CCR was 0.25.
2.4.5.2.2 First, calculate 65% of the operating
threshold amount for the case. Add the full DRG payment of $20,000
to the CY 2021 TRICARE fixed-loss threshold amount ($29,064). The
DRG payment added to the fixed loss threshold equals the operating
threshold amount for the claim = $20,000 + $29,064 = $49,064. Then
multiply the operating threshold amount by a factor of 65% to determine
the potential add-on payment, $49,064 x 0.65 = $31,891.60.
2.4.5.2.3 Second, calculate 65% of the difference
between the full DRG payment and the cost of the case. Multiply
the billed charge amount of $100,000 by the CCR of 0.25, $100,000
x 0.25 = $25,000. Then the difference between the estimated cost
of the case and the full DRG payment is calculated as $25,000 -
$20,000 = $5,000. Finally, multiply the difference ($5,000) by a
factor of 0.65 to calculate the potential add-on payment, $5,000
x 0.65 = $3,250.
2.4.5.2.5 In this example, the contractor
shall pay the NCTAP of $3,250 on top of the full DRG payment, including
any CARES Act adjustments such as the 20% increase in the DRG weight.