| (viii) Subtract the DRG payment amount calculated in
clause (iii) of this subparagraph from the cost calculated in clause
(vii) of this subparagraph.
(ix) The day outlier amount is the lesser of the amount
in clause (vi) of this subparagraph or the amount in clause (viii)
of this subparagraph.
(x) For urban and rural hospitals, multiply the amount
in clause (ix) of this subparagraph by 90 percent to determine the
final day outlier amount. For children's hospitals the amount in clause
(ix) of this subparagraph is the final day outlier amount.
(B) Cost outlier payment adjustment. HHSC makes a cost
outlier payment adjustment for an extraordinarily high-cost claim
as follows.
(i) To establish a cost outlier, the cost outlier threshold
must be determined by first selecting the lesser of the universal
mean of base year claims and rural base year stays multiplied by 11.14
or the hospital's final SDA multiplied by 11.14.
(ii) Multiply the full DRG prospective payment by 1.5.
(iii) The cost outlier threshold is the greater of
clause (i) or (ii) of this subparagraph.
(iv) Subtract the cost outlier threshold from the amount
of reimbursement for the claim established under cost reimbursement
principles described in the Tax Equity and Fiscal Responsibility Act
of 1982 (TEFRA).
(v) Multiply the result in clause (iv) of this subparagraph
by 60 percent to determine the amount of the cost outlier payment.
(vi) For urban and rural hospitals, multiply the amount
in clause (v) of this subparagraph by 90 percent to determine the
final cost outlier amount. For children's hospitals the amount in
clause (v) of this subparagraph is the final cost outlier amount.
(C) Final outlier determination.
(i) If the amount calculated in subparagraph (A)(ix)
of this paragraph is greater than zero and the amount calculated in
subparagraph (B)(vi) of this paragraph is greater than zero, HHSC
pays the higher of the two amounts.
(ii) If the amount calculated in subparagraph (A)(ix)
of this paragraph is greater than zero and the amount calculated in
subparagraph (B)(vi) of this paragraph is less than or equal to zero,
HHSC pays the day outlier amount.
(iii) If the amount calculated in subparagraph (B)(vi)
of this paragraph is greater than zero and the amount calculated in
subparagraph (A)(ix) of this paragraph is less than or equal to zero,
HHSC pays the cost outlier amount.
(iv) If the amount calculated in subparagraph (A)(ix)
of this paragraph and the amount calculated in subparagraph (B)(vi)
of this paragraph are both less than or equal to zero HHSC will not
pay an outlier for the admission.
(D) If the hospital claim resulted in a downgrade of
the DRG related to reimbursement denials or reductions for preventable
adverse events, the outlier payment will be determined by the lesser
of the calculated outlier payment for the non-downgraded DRG or the
downgraded DRG.
(4) Interim bill. A hospital may submit a claim to
HHSC before a patient is discharged, but only the first claim for
that patient will be reimbursed the prospective payment described
in paragraph (1) of this subsection. Subsequent claims for that stay
are paid zero dollars. When the patient is discharged, and the hospital
submits a final claim to ensure accurate calculation for potential
outlier payments for clients younger than age 21, HHSC recoups the
first prospective payment and issues a final payment in accordance
with paragraphs (1) and (3) of this subsection.
(5) Patient transfers and split billing. If a patient
is transferred, HHSC establishes payment amounts as specified in subparagraphs
(A) - (D) of this paragraph. HHSC manually reviews transfers for medical
necessity and payment.
(A) If the patient is transferred from a hospital to
a nursing facility, HHSC pays the transferring hospital the total
payment amount of the patient's DRG.
(B) If the patient is transferred from one hospital
(transferring hospital) to another hospital (discharging hospital),
HHSC pays the discharging hospital the total payment amount of the
patient's DRG. HHSC calculates a DRG per diem and a payment amount
for the transferring hospital as follows.
(i) Multiply the DRG relative weight by the final SDA.
(ii) Divide the result in clause (i) 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.
(iii) To arrive at the transferring hospital's payment
amount:
(I) for a patient age 21 or older, multiply the result
in clause (ii) of this subparagraph by the lesser of the DRG MLOS,
the transferring hospital's number of medically necessary days allowed
for the claim, or 30 days; or
(II) for a patient under age 21, multiply the result
in clause (ii) of this subparagraph by the lesser of the DRG MLOS
or the transferring hospital's number of medically necessary days
allowed for the claim.
(C) HHSC makes payments to multiple hospitals transferring
the same patient by applying the per diem formula in subparagraph
(B) of this paragraph to all the transferring hospitals and the total
DRG payment amount to the discharging hospital.
(D) HHSC performs a post-payment review to determine
if the hospital that provided the most significant amount of care
received the total DRG payment. If the review reveals that the hospital
that provided the most significant amount of care did not receive
the total DRG payment, an adjustment is initiated to reverse the payment
amounts. The transferring hospital is paid the total DRG payment amount
and the discharging hospital is paid the DRG per diem.
(j) Cost reports. Each hospital must submit an initial
cost report at periodic intervals as prescribed by Medicare or as
otherwise prescribed by HHSC.
(1) Each hospital must send a copy of all cost reports
audited and amended by a Medicare intermediary to HHSC within 30 days
after the hospital's receipt of the cost report. Failure to submit
copies or respond to inquiries on the status of the Medicare cost
report will result in provider vendor hold.
(2) HHSC uses data from these reports when realigning
or rebasing to calculate base SDAs, DRG statistics, and interim rates
and to complete cost settlements.
(k) Cost Settlement.
(1) The cost settlement process is limited by the TEFRA
target cap set pursuant to the Social Security Act §1886(b) (42
U.S.C. §1395ww(b)) for children's and state-owned teaching hospitals.
(2) Notwithstanding the process described in paragraph
(1) of this subsection, HHSC uses each hospital's final audited cost
report, which covers a fiscal year ending during a base year period,
for calculating the TEFRA target cap for a hospital.
(3) HHSC may select a new base year period for calculating
the TEFRA target cap at least every three years.
(4) HHSC increases a hospital's TEFRA target cap in
years in which the target cap is not reset under this paragraph, by
multiplying the hospital's target cap by the CMS Prospective Payment
System Hospital Market Basket Index adjusted to the hospital's fiscal
year.
(5) For a new children's hospital, the base year for
calculating the TEFRA target cap is the hospital's first full 12-month
cost reporting period occurring after the date the hospital is designated
by Medicare as a children's hospital. For each cost reporting period
after the hospital's base year, an increase in the TEFRA target cap
will be applied as described in paragraph (4) of this subsection,
until the TEFRA target cap is recalculated as described in paragraph
(3) of this subsection.
(6) After a Medicaid participating hospital is designated
by Medicare as a children's hospital, the hospital must submit written
notification to HHSC's provider enrollment contact, including documents
verifying its status as a Medicare children's hospital. Upon receipt
of the written notification from the hospital, HHSC will convert the
hospital to the reimbursement methodology described in this subsection
retroactive to the effective date of designation by Medicare.
(l) Out-of-state children's hospitals. HHSC calculates
the prospective payment rate for an out-of-state children's hospital
as follows:
(1) HHSC determines the overall average cost per discharge
for all in-state children's hospitals by:
(A) summing the Medicaid allowed cost from tentative
or final cost report settlements for the base year; and
(B) dividing the result in subparagraph (A) of this
paragraph by the number of in-state children's hospitals' base year
claims.
(2) HHSC determines the average relative weight for
all in-state children's hospitals' base year claims by:
(A) assigning a relative weight to each claim pursuant
to subsections (g)(1)(B)(iii) or (h)(2)(B)(iii) of this section;
Cont'd... |
