California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 5.5 - Application of the Official Medical Fee Schedule (Treatment)
Section 9792.1 - Payment of Inpatient Services of Health Facilities
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Maximum reimbursement for inpatient medical services shall be determined by multiplying 1.20 by the product of the health facility's composite factor and the applicable DRG weight or revised DRG weight if a revised weight has been adopted by the administrative director. The fee determined under this subdivision shall be a global fee, constituting the maximum reimbursement to a health facility for inpatient medical services not exempted under this section. However, preadmission services rendered by a health facility more than 24 hours before admission are separately reimbursable.
(b) Health facilities billing for fees under this section shall present with their bill the name and address of the facility, the facility's Medicare ID number, and the applicable DRG codes.
(c) The following are exempt from the maximum reimbursement formula set forth in subdivision (a):
Step 1: Determine the Inpatient Hospital Fee Schedule payment amount (DRG relative weight x 1.2 x hospital specific composite factor).
Step 2: Determine costs. Costs = (total billed charges x total cost-to-charge ratio).
Step 3: Determine outlier threshold. Outlier threshold = (Inpatient Hospital Fee Schedule payment amount + hospital specific outlier factor).
If costs exceed the outlier threshold, the case is a cost outlier case and the admission is reimbursed at the Inpatient Hospital Fee Schedule payment amount + (0.8 x (costs - cost outlier threshold)).
NOTE: For purposes of determining whether a case qualifies as a cost outlier case under this subsection, implantable hardware and/or instrumentation reimbursed under subsection (8) below is excluded from the calculation of costs. Once an admission for DRGs 496 through 500 qualifies as a cost outlier case, any implantable hardware and/or instrumentation shall be separately reimbursed under subsection (8) below.
(d) Any health care facility that believes its composite factor or hospital specific outlier factor was erroneously determined because of an error in tabulating data may request the Administrative Director for a re-determination of its composite factor or hospital specific outlier factor. Such requests shall be in writing, shall state the alleged error, and shall be supported by written documentation. Within 30 days after receiving a complete written request, the Administrative Director shall make a redetermination of the composite factor or hospital specific outlier factor or reaffirm the published factor.
(e) This section, except as provided in subsections (c)(7) and (c)(8), shall apply to covered inpatient hospital stays for which the day of admittance is on or after April 1, 1999.
(f) Subsections (c)(7) and (c)(8) shall remain in effect only through December 31, 2001, and shall not apply to admissions occurring on or after January 1, 2002.
AN IMPORTANT NOTE CONCERNING SUBSECTIONS (c)(7) AND (c)(8):
Labor Code Section 5318, (as added by Statutes of 2001, chapter 252, effective January 1, 2002,) provides that: "Notwithstanding any other provision of law, the termination date of December 31, 2001, provided in Section of Title 89792.1(f) of Title 8 of the California Code of Regulations shall be extended until the effective date of new regulations adopted by the administrative director, as required by Section 5307.1, providing for the biennial review of the fee schedule for health care facilities." Sections 9792.1(c)(7) and (c)(8) will therefore remain in effect for admissions on or after January 1, 2002, and will not sunset.
1. New
section filed 12-31-96; operative 12-31-96 pursuant to Government Code section
11343.4(d).
Submitted to OAL for printing only pursuant to Government Code section
11351
(Register 97, No. 1).
2. Amendment of section and new appendices A-C
filed 2-23-99; operative 4-1-99 (Register 99, No. 9).
3. New
subsection (c)(8), amendment of subsection (e) and new subsection (f) filed
3-14-2001; operative 4-13-2001. Submitted to OAL for printing only pursuant to
Government Code section
11343(a)(1)
(Register 2001, No. 22).
4. Amendment of section and repealer and
new Appendices A and B filed 5-30-2001; operative 6-29-2001. Submitted to OAL
for printing only pursuant to Government Code section
11340.9(g)
(Register 2001, No. 23).
5. Change without regulatory effect adding
final two paragraphs and amending NOTE filed 12-31-2001 pursuant to section
100, title 1, California Code of
Regulations (Register 2002, No. 1).
Note: Authority cited: Sections 133, 4603.5, 5307.1, 5307.3 and 5318, Labor Code. Reference: Sections 4600, 4603.2, 5307.1 and 5318, Labor Code.
