Hospital Inpatient DRG Reconciliation Sandy Sage RN March 23, 2016.

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Presentation transcript:

Hospital Inpatient DRG Reconciliation Sandy Sage RN March 23, 2016

DRG Conversion Passed by the Florida Legislature in 2012 Transitioned Medicaid hospital inpatient payment from per diem to a DRG system Applies to all hospitals except inpatient psychiatric hospitals Implemented in 2013 http://www.fdhc.state.fl.us/medicaid/cost_reim/pdf/DRG_Payment-Conversion_Implementation_Plan-FL_AHCA-Final.pdf

What is a DRG payment? Payment based on the following: Diagnosis Surgical procedures performed, if any Patient age Patient gender Discharge status

Relative Weight Each diagnosis is assigned a DRG code Each code is assigned a relative weight which indicates the amount of resources required to treat a patient with that diagnosis DRG rate for an average Florida hospital admission is 1.0 and can be used to determine the complexity of each diagnosis Example: If a DRG has a relative weight of 2.0 the stay requires 2 x the resources as an average stay

Payment Adjustments DRG base payments can be increased by a “Policy Adjustor” Provider Adjusters are applied for rural hospitals and hospitals with high Medicaid utilization Transfers: Payment is usually decreased if a patient is transferred Cost outlier adjustments may be applied Charge cap: payment will be the lesser of DRG payment or charge amounts http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/DRG%20PRICING/Quick%20Reference%20and%20Awareness%20Guide.pdf

What’s New? Original base payment $ 3230.64 2015 General Appropriations Act (GAA) required AHCA to apply adjustments to the base rate, complex calculation 3/2016 through 6/2016 base rate recalculated will be a decrease of 4.9% $ 3078.81

UPDATES Get Medicaid updates and alerts by email: Archive of alerts: ahca.myflorida.com/Medicaid/alerts/alerts_edit.shtml Archive of alerts: http://portal.flmmis.com/FLPublic/Provider_Provid erServices/Provider_ProviderSupport/Provider_Prov iderSupport_ProviderAlerts/tabId/48/Default.aspx

Helpful Links DRG Pricing Page: http://portal.flmmis.com/FLPublic/Provider_AgencyIn itiatives/Provider_DRG/tabId/91/Default.aspx DRG Fiscal Year 2015-2016 Changes [459KB] *New 08/03/15* DRG Fiscal Year 2014-2015 Changes [360KB] DRG Quick Reference and Awareness Guide [1739KB] DRG Frequently Asked Questions (FAQ) [991KB] Understanding Diagnosis Related Groups (DRG) Training Presentation [1587KB] DRG Field Services Representatives Area Map [390KB]

Contact Information Sandy Sage RN SandySageRN@Gmail.com 478-290-4155