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

2. 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

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

4. 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

5. 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

6. 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% $

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

8. Helpful Links DRG Pricing Page:
itiatives/Provider_DRG/tabId/91/Default.aspx
DRG Fiscal Year Changes [459KB] *New 08/03/15* DRG Fiscal Year 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]

9. Contact Information Sandy Sage RN