Examples: Calculating Reimbursement Under the Episodic Payment System

Episodic Payment System: Reimbursement Examples is also available in Portable Document Format (PDF, 1.31MB, 9pg.)

Episodic Payment System: Reimbursement Examples

The following pages provide 6 examples of how payments to providers will be calculated:

  1. Interim Payment
  2. Full episode - no LUPA, no outlier reimbursement
  3. Full episode - with outlier reimbursement
  4. Full episode - LUPA
  5. Partial episode - no LUPA, no outlier reimbursement
  6. Partial episode - with outlier reimbursement

The following information will apply to all 6 payment examples:

  • Patient is served by a CHHA in New York City
  • Reason for OASIS assessment is Recertification (1)
  • Clinical group is B
  • Functional Group is F
  • Patient is 72 years old (Age Group 3)

  • Statewide Base Price is $5,633
  • Case Mix Index for Resource Group 1-B-F-3 = 0.934108
  • Outlier Threshold for 1-B-F-3 = $9,720
  • Wage Index applied to 77% of reimbursement

Example #1: Interim Payment (1BF3)

Base Price: $5,633 × Case Mix .934108 = Statewide Case Mix Adjusted Price $5,261.83 ×
NYC Wage Index Factor (.991433) - Applied to 77% of Statewide Case Mix Adjusted Price = Total Price Adjusted for Case Mix and Wage Index $5,227.12 × .5 (50% of Price Adj. for Case Mix and Wage Index) $2,613.56

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Example #2: Full Episode - No LUPA, No Outlier Adjustment (1BF3)

Base Price: $5,633 × Case Mix .934108 = Statewide Case Mix Adjusted Price $5,261.83

Statewide Case Mix Adjusted Price $5,261.83 × NYC Wage Index Factor (.991433) - Applied to 77% of Statewide Case Mix Adjusted Price = Total Price Adjusted for Case Mix and Wage Index $5,227.12

(If Interim Payment was received, provider will receive Final Payment of $5,227 .12 minus "takeback" of Interim Payment - e.g. $2,613.56 in Example #1).

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Example #3: Full Episode with Outlier Reimbursement

Total charges for visits, hours, etc. reported by CHHA based on Revenue Codes = $12,000

Outlier Threshold for this Resource Group = $9,720

Charges in excess of outlier threshold = $2,280

Provider will receive outlier payment of $2,280 × 50% = $1,140 77% of this amount will be adjusted by Wage Index Factor Net outlier payment (NYC Provider) = $1,132.48

Base Price adjusted for WIF and Case Mix (from Example #1): $5,227.12 + Outlier Payment, adjusted for WIF: $1,132.48 = Total Episodic Payment: $6,359.60

(Interim Payment, if any, will be deducted when Final Payment is made)

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Example #4: Full Episode - Low Utilization (LUPA) (1BF3)

Total charges for visits, hours, etc. reported by CHHA based on Revenue Codes = $450.00

As this is less than (or equal to) $500.00, Low Utilization Payment will apply - REGARDLESS of length of episode

Provider will receive actual charges produced by Revenue Codes:
77% of this amount will be adjusted by Wage Index Factor Net payment (NYC Provider) = $447.03

(Interim Payment, if any, will be deducted when Final Payment is made)

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Example #5: Partial Episode - No LUPA, No Outlier Adjustment (1BF3)

"From" Date on Claim Form: May 15, 2012

"Through" Date on Claim Form: June 23, 2012

Length of Episode: 40 Days

Episodic Price Adjusted for Wage Index Factor and Case Mix (from Example #1): $5,227.12 × 40 / 60 = Total Reimbursement for Partial Episode: $3,484.75

(Interim Payment, if any, will be deducted when Final Payment is made)

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Example #6: Partial Episode with Outlier Reimbursement (1BF3)

"From" Date on Claim Form: May 15, 2012

"Through" Date on Claim Form: June 23, 2012

Length of Episode: 40 Days

Total charges for visits, hours, etc. reported by CHHA based on Revenue Codes = $12,000

Charges in excess of outlier threshold = $2,280

Full Episodic Price Adjusted for WIF and Case Mix (from Example #1): $5,227.12 + Outlier Payment adjusted for WIF (from Example #3): $1,132.48 = Total Payment Before Adjustment for Partial Period: $6,359.60 × 40 / 60 = Total Payment for Partial Episode: $4,239.73

(Interim Payment, if any, will be deducted when Final Payment is made)

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