| (5) Biennial review of rural rates. Every two years,
HHSC will calculate new rural SDAs using the methodology in this subsection
to the extent allowed by federal law and subject to limitations on
appropriations.
(f) Final SDA for military and out-of-state. The final
SDA for military and out-of-state hospitals is the urban hospital
base SDA multiplied by the percentage determined in subsection (d)(4)(D)
of this section.
(g) DRG statistical calculations. HHSC rebases the
relative weights, MLOS, and day outlier threshold whenever the base
SDAs for urban hospitals are recalculated. The relative weights, MLOS,
and day outlier thresholds are calculated using data from urban hospitals
and apply to all hospitals. The relative weights that were implemented
for urban hospitals on September 1, 2012, apply to all hospitals until
the next realignment.
(1) Recalibration of relative weights. HHSC calculates
a relative weight for each DRG as follows.
(A) Base year claims are grouped by DRG.
(B) For each DRG, HHSC:
(i) sums the base year costs per DRG as determined
in subsection (d) of this section;
(ii) divides the result in clause (i) of this subparagraph
by the number of claims in the DRG; and
(iii) divides the result in clause (ii) of this subparagraph
by the universal mean, resulting in the relative weight for the DRG.
(2) Recalibration of the MLOS. HHSC calculates the
MLOS for each DRG as follows.
(A) Base year claims are grouped by DRG.
(B) For each DRG, HHSC:
(i) sums the number of days billed for all base year
claims; and
(ii) divides the result in clause (i) of this subparagraph
by the number of claims in the DRG, resulting in the MLOS for the
DRG.
(3) Recalibration of day outlier thresholds. HHSC calculates
a day outlier threshold for each DRG as follows.
(A) Calculate for all claims the standard deviations
from the MLOS in paragraph (2) of this subsection.
(B) Remove each claim with a length of stay (number
of days billed by a hospital) greater than or equal to three standard
deviations above or below the MLOS. The remaining claims are those
with a length of stay less than three standard deviations above or
below the MLOS.
(C) Sum the number of days billed by all hospitals
for a DRG for the remaining claims in subparagraph (B) of this paragraph.
(D) Divide the result in subparagraph (C) of this paragraph
by the number of remaining claims in subparagraph (B) of this paragraph.
(E) Calculate one standard deviation for the result
in subparagraph (D) of this paragraph.
(F) Multiply the result in subparagraph (E) of this
paragraph by two and add that to the result in subparagraph (D) of
this paragraph, resulting in the day outlier threshold for the DRG.
(4) If a DRG has fewer than five base year claims,
HHSC will use National Claim Statistics and a scaling factor to assign
a relative weight, MLOS, and day outlier threshold.
(5) Adjust the MLOS, day outlier, and relative weights
to increase or decrease with SOI to coincide with the National Claim
Statistics.
(h) DRG grouper logic changes. Beginning September
1, 2021, HHSC may adjust DRG statistical calculations to align with
annual grouper logic changes. The changes will remain budget neutral
unless rates are rebased, and additional funding is appropriated by
the legislature. The adjusted relative weights, MLOS, and day outlier
threshold apply to all hospitals until the next adjustment or rebasing
described in subsection (g) of this section.
(1) Base year claim data and rural base year stays
are regrouped, using the latest grouping software version to determine
DRG assignment changes by comparing the newly assigned DRG to the
DRG assignment from the previous grouper version.
(2) For DRGs impacted by the grouping logic changes,
relative weights must be adjusted. HHSC adjusts a relative weight
for each impacted DRG as follows.
(A) Divide the total cost for all claims in the base
year by the number of claims in the base year.
(B) Base year claims and rural base year stays are
grouped by DRG, and for each DRG, HHSC:
(i) sums the base year costs for all claims in each
DRG;
(ii) divides the result in clause (i) of this subparagraph
by the number of claims in each DRG; and
(iii) divides the result in clause (ii) of this subparagraph
by the amount determined in subparagraph (A) of this paragraph, resulting
in the relative weight for the DRG.
(3) Recalibration of the MLOS. HHSC calculates the
MLOS for each DRG as follows.
(A) Base year claims and rural base year stays are
grouped by DRG.
(B) For each DRG, HHSC:
(i) sums the number of days billed for all base year
claims; and
(ii) divides the result in clause (i) of this subparagraph
by the number of claims in the DRG, resulting in the MLOS for the
DRG.
(4) Recalibration of day outlier thresholds. HHSC calculates
a day outlier threshold for each DRG as follows.
(A) Calculate for all claims the standard deviations
from the MLOS in paragraph (3) of this subsection.
(B) Remove each claim with a length of stay (number
of days billed by a hospital) greater than or equal to three standard
deviations above or below the MLOS. The remaining claims are those
with a length of stay less than three standard deviations above or
below the MLOS.
(C) Sum the number of days billed by all hospitals
for a DRG for the remaining claims in subparagraph (B) of this paragraph.
(D) Divide the result in subparagraph (C) of this paragraph
by the number of remaining claims in subparagraph (B) of this paragraph.
(E) Calculate one standard deviation for the result
in subparagraph (D) of this paragraph and multiply by two.
(F) Add the result of subparagraph (E) of this paragraph
to the result in subparagraph (D) of this paragraph, resulting in
the day outlier threshold for the DRG.
(5) If a DRG has fewer than five base year claims,
HHSC will use National Claim Statistics and a scaling factor to assign
a relative weight, MLOS, and day outlier threshold.
(6) Adjust the MLOS, day outliers, and relative weights
to increase or decrease with SOI to coincide with the National Claim
Statistics.
(i) Reimbursements.
(1) Calculating the payment amount. HHSC reimburses
a hospital a prospective payment for covered inpatient hospital services
by multiplying the hospital's final SDA as calculated in subsections
(c) - (f) of this section as applicable, by the relative weight for
the DRG assigned to the adjudicated claim. The resulting amount is
the payment amount to the hospital.
(2) Full payment. The prospective payment as described
in paragraph (1) of this subsection is considered full payment for
covered inpatient hospital services. A hospital's request for payment
in an amount higher than the prospective payment will be denied.
(3) Day and cost outlier adjustments. HHSC pays a day
outlier or a cost outlier for medically necessary inpatient services
provided to clients under age 21 in all Medicaid participating hospitals
that are reimbursed under the prospective payment system. If a patient
age 20 is admitted to and remains in a hospital past his or her 21st
birthday, inpatient days and hospital charges after the patient reaches
age 21 are included in calculating the amount of any day outlier or
cost outlier payment adjustment.
(A) Day outlier payment adjustment. HHSC calculates
a day outlier payment adjustment for each claim as follows.
(i) Determine whether the number of medically necessary
days allowed for a claim exceeds:
(I) the MLOS by more than two days; and
(II) the DRG day outlier threshold as calculated in
subsection (g)(3) of this section.
(ii) If clause (i) of this subparagraph is true, subtract
the DRG day outlier threshold from the number of medically necessary
days allowed for the claim.
(iii) Multiply the DRG relative weight by the final
SDA.
(iv) Divide the result in clause (iii) of this subparagraph
by the DRG MLOS described in subsections (g)(2) or (h)(3) of this
section to arrive at the DRG per diem amount.
(v) Multiply the number of days in clause (ii) of this
subparagraph by the result in clause (iv) of this subparagraph.
(vi) Multiply the result in clause (v) of this subparagraph
by 60 percent.
(vii) Multiply the allowed charges by the current interim
rate to determine the cost.
Cont'd... |
