WORKER'S COMP - NO FAULT PSYCH REFORM ONLY/HOSPITAL- PAYMENTS

Sample Payment Calculation Worksheet

Line Calculation Elements Worker´s Compensation,
No Fault, Volunteer
Firefighters, Volunteer
Ambulance Workers
EXEMPT UNIT/HOSPITAL ACUTE CARE PAYMENT: Data Source and Formulas
1. Exempt Unit/Hospital Stay Days
a. Total Number of Days in Stay (inc. ALC) Medical Record
b. Alternate Level of Care (ALC) Days Medical Record
c. Total Acute Care Days excluding ALC Line 1a - Line 1b
2. Acute Per Diem Rate or Alternate Payment Per Diem See Applicable WCNF Rate Publication Psych Operating Billing Rate (Col 1)
3. Per Case Service Intensity Weight for Psych DRG Classification *SIW APR-DRG Table (DOH)
4. Age Adjustment Factor Age Factor (17 & under=1.0872, 18 & over =1.0000)
5. Mental Retardation Factor 1.0599
6. Comorbidity Factor(s) *Comorbidity Weight Factors (DOH) (If more than 1 exists, use highest weight factor)
7. LOS Scale Factor Days 1-4=1.20 Days 5-11=1.00 Days 12-22=0.96 Days 23 & over=0.92
8. Non-Operating Billing Component (capital, etc) See Applicable WCNF Rate Publication for Psych Non-Operating Billing Rate (Col 2)
9. Electro Convulsive Therapy (ECT) Component See Applicable WCNF Rate Publication for Psych ECT Payment (Col 3) (x number of treatments)
10. Total Payment at 100% Line 2 x Line 3 x Line 4 x Line 5 x Line 6 x Line 7 + Line 8 + Line 9
ALTERNATE LEVEL OF CARE (ALC) PAYMENT:
11. CALCULATION OF ALC PAYMENT:
(a) Alternate Level of Care Billing Rate See Applicable WCNF Rate Publication for Psych ALC Per Diem (Col 4)
(b) Number of ALC Days Line 1b
(c) Total ALC Payment Line 11a x Line 11b
TOTAL PAYMENT AMOUNT:
12. Total Exempt Unit/Hospital w/ALC Payment at 100% Line 10 + Line 11c
∗
Footnotes:
Surcharge April 1, 2009========> Pay Directly To Pool
9.63%
Surcharge April 1, 2009========> Pay To Hospital
9.63% & 28.27%