Out of State Medicaid FFS Claims Payment Calculations

INLIER

Line Calculation Elements Traditional
Medicaid
Fee For Service
(Out-of-State)
INLIER PAYMENT: Data Source and Formulas
CALCULATION OF INLIER PAYMENT:
1. Discharge Case Payment Rate (Without IME for Medicaid Managed Care) OOS_MA_FFS_Acute_Rate Code 2953_Col 1
2. Per Case Service Intensity Weight for DRG Classification SIW APR-DRG Table (DOH*)
3. Case Mix Adjusted Discharge Payment Line 1 × Line 2
4. Direct Medical Education (DME) Add-On OOS_MA_FFS_Acute_Rate Code 2589_Col 3
5. Capital per Discharge Rates (plus non-comparable add-ons where applicable) OOS_MA_FFS_Acute_Rate Code 2990_Col 6
6. Inlier DRG Payment Line 3 + Line 4 + Line 5
ALTERNATE LEVEL OF CARE (ALC) PAYMENT:
7. CALCULATION OF ALC PAYMENT:
(a) Alternate Level of Care (ALC) Price Per Day OOS_MA_FFS_Acute_Rate Code 2950, 2951_Col 4, Col 5
(b) Alternate Level of Care (ALC) Days Medical Record
(c) Total ALC Payment Line 7a × Line 7b
TOTAL PAYMENT AMOUNT:
8. Total Inlier with ALC Payment at 100% Line 6 + Line 7c
MEDICAID SURCHARGE CALCULATION:
A Medicaid Surcharge (Indigent Care and Health Care Initiative Surcharge) 4/1/09 Forward ==> 7.04%
B Medicaid Surcharge Amount Line 8 × Line A
C Payment to Hospital if Provider Signed Authorization for Medicaid Direct Payment of Surcharge to the Pool Administrator. Line 8
D Payment to Hospital if Provider Did Not Sign Authorization for Medicaid Direct Payments - Hospital Pays Surcharge to the Pool Administrator. Line 8 + Line B

∗The SIW APR-DRG Table is available on the DOH public website at: http://www.nyhealth.gov/facilities/hospital/reimbursement/apr-drg/weights/

TRANSFER

Total Transfer Payment cannot exceed the amount that would have been paid if the patient had been discharged (Inlier)
Line Calculation Elements Traditional
Medicaid
Fee For Service
(Out-of-State)
TRANSFER DATA: Data Source and Formulas
1. TRANSFER DAYS DETERMINATION:
(a) Total Number of Days in Stay (inc. ALC) Medical Record
(b) Alternate Level of Care (ALC) Days Medical Record
(c) Number of Days excluding ALC Line 1a − 1b
2. Is this Case a Transfer? Your Hospital Data
o not use this methodology for patients assigned to a DRG specifically designated as a DRG for transfer patient only [i.e., neonate transferred < 5 days (DRGs 580 & 581)].
CALCULATION OF TRANSFER PAYMENT:
3. Discharge Case Payment Rate OOS_MA_FFS_Acute_Rate Code 2953_Col 1
4. Per Case Service Intensity Weight for DRG Classification SIW APR-DRG Table (DOH*)
5. Case Mix Adjusted Discharge Payment Line 3 × Line 4
6. Statewide Average Arithmetic Inlier LOS for DRG SIW APR-DRG Table (DOH*)
7. Average Inlier Cost Per Day Line 5 ÷ Line 6
8. TRANSFER ADJUSTMENT FACTOR:
(a)


(b)
If Statewide Average Arithmetic Inlier LOS for the DRG = 1, then Transfer Adj. Factor is 100%
OR
If Group Average Arithmetic Inlier LOS for the DRG > 1, then Transfer Adj. Factor is 120%

100%
or
120%
9. Transfer DRG Cost Per Day Line 7 × Line 8a (or 8b)
10. Case Payment Capital per Diem OOS_MA_FFS_Acute_Rate Code 2991_Col 7
11. Total Transfer Cost Per Diem Line 9 + Line 10
TRANSFER PAYMENT: Data Source and Formulas
12. Transfer Payment Amount excluding DME Line 11 × Line 1c
13. Direct Medical Education (DME) Add-On OOS_MA_FFS_Acute_Rate Code 2589_Col 3
14. Transfer Payment Amount Before ALC Line 12 + Line 13
15. Discharge DRG Test:
(a) Inlier DRG Before ALC Inlier Tab, Line 6
16. Total Transfer Payment Before ALC Lesser of Line 14 or Line 15a
17. Total ALC Payment Inlier Tab, Line 7c
18. Total Transfer with ALC Payment at 100% Line 16 + Line 17
MEDICAID SURCHARGE CALCULATION: Data Source and Formulas
A Medicaid Surcharge (Indigent Care and Health Care Initiative Surcharge) 4/1/09 Forward ==> 7.04%
B Medicaid Surcharge Amount Line 18 × Line A
C Payment to Hospital if Provider Signed Authorization for Medicaid Direct Payment of Surcharge to the Pool Administrator. Line 18
D Payment to Hospital if Provider Did Not Sign Authorization for Medicaid Direct Payments - Hospital Pays Surcharge to Pool Administrator. Line 18 + Line B

∗The SIW APR-DRG Table is available on the DOH public website at: http://www.nyhealth.gov/facilities/hospital/reimbursement/apr-drg/weights/

HIGH COST

HIGH COST OUTLIER PAYMENT IS IN ADDITION TO INLIER PAYMENT CALCULATED ON THE INLIER WORKSHEET TAB.
Line Calculation Elements Traditional
Medicaid
Fee For Service
(Out-of-State)
HIGH COST OUTLIER PAYMENT: Data Source and Formulas
1. Total Inpatient Gross Charges Per Patient UB-92, HCFA 1450 Charge Master
2. Adjustment to Total Inpatient Gross Charges:
a. Telephone and Telegraph Charge Master
b. Television and Radio Charge Master
c. Private Room Differential Charge Master
d. Other Non-Covered Charge Master
e. Gross Charges for all ALC Days Charge Master
f. Total Adjustments Sum of Lines 2a thru 2e
3. Net Inpatient Gross Charges Line 1 − Line 2f
4. High Cost Charge Converter OOS_MA_FFS_Acute_Rate Code 2953_Col 9
5. Net Inpatient Gross Charges Converted to Costs Line 3 × Line 4
6. Threshold Calculation:
a. APR-DRG Cost Outlier Threshold Outlier Threshold Table (DOH*)
b. Institution-Specific Adjustment Factor (ISAF/WEF) OOS_MA_FFS_Acute_Rate Code 2953_Col 8
c. Adjusted Cost Outlier Threshold Line 6a × Line 6b
7. High Cost Payment Test:
a. Do costs exceed the threshold? Is Line 5 > 6c?
b. Does the case involve a Transfer? Determination per Your Hospital Data
CONTINUE WITH CALCULATION IF LINE 7a= "Yes" AND THE CASE IS NOT A TRANSFER.
[High Cost Outlier does not apply to Transfer Cases (other than patients assigned to transfer DRGs) per 86-1.21.]
HIGH COST OUTLIER PAYMENT: Data Source and Formulas
8. High Cost Outlier Payment before Inlier and ALC (100% of costs above adjusted threshold) Line 5 − Line 6c
9. Total Inlier with ALC Payment at 100% Inlier Worksheet Tab, Line 8
10. Total Payment to Provider at 100% Line 8 + Line 9
MEDICAID SURCHARGE CALCULATION: Data Source and Formulas
A Medicaid Surcharge (Indigent Care and Health Care Initiative Surcharge) 4/1/09 Forward ==> 7.04%
B Medicaid Surcharge Amount Line 10 × Line A
C Payment to Hospital if Provider Signed Authorization for Medicaid Direct Payment of Surcharge to the Pool Administrator. Line 10
D Payment to Hospital if Provider Did Not Sign Authorization for Medicaid Direct Payments - Hospital Pays Surcharge to Pool Administrator. Line 10 + Line B

∗The SIW APR-DRG Table is available on the DOH public website at: http://www.health.ny.gov/facilities/hospital/reimbursement/apr-drg/tresholds/