Current through September 24, 2024
A. For
admissions dated October 1, 2012, and after, the Division of Medicaid
reimburses all hospitals a per stay rate based on All Patient Refined Diagnosis
Related Groups (APR-DRGs). APR-DRGs classify each case based on information
contained on the inpatient Medicaid claim including diagnosis, procedures
performed, patient age, patient sex, and discharge status. The APR-DRG payment
is determined by multiplying the APR-DRG relative weight by the APR-DRG base
rate. Medicaid uses a prospective method of reimbursement and will not make
retroactive adjustments except as specified in the Title XIX Inpatient Hospital
Reimbursement Plan.
B. The Division
of Medicaid may adjust APR-DRG rates pursuant to changes in federal and/or
state laws or regulations or to obtain budget goals. All Plan changes must be
authorized by the Mississippi Legislature and federal grantor agency,
C. Extraordinarily costly cases in relation
to other cases within the same DRG because of the severity of the illness or
complicating conditions may qualify for a cost outlier payment. This is an
add-on payment for expenses that are not predictable by the diagnoses,
procedures performed, and other statistical data captured by the DRG grouper.
1. The additional payment for a cost outlier
is determined by calculating the hospital's estimated loss. The estimated loss
is determined by multiplying the covered charges by the hospital's inpatient
cost-to-charge ratio minus the DRG base payment. If the estimated loss is
greater than the DRG cost outlier threshold established by the Division of
Medicaid, then the cost outlier payment equals the estimated loss minus the DRG
cost outlier threshold multiplied by the DRG Marginal Cost Percentage. For
purposes of this calculation, the DRG base payment is net of any applicable
transfer adjustment.
2. Stays
assigned to mental health DRGs are not eligible for cost outlier payments, but
may qualify for a day outlier payment if the mental health stay exceeds the DRG
Long Stay Threshold.
D.
Cost-to-Charge Ratio (CCR) Used to Calculate Cost Outlier Payments
1. The Cost-to-Charge Ratios (CCRs) used to
calculate cost outlier payments are calculated for each provider by performing
a desk review program developed by the Division of Medicaid, using the most
recent filed cost report. The Division accepts amended original cost reports if
the cost report is submitted prior to the end of the reimbursement period in
which the cost report is used for payment purposes. If the provider's inpatient
cost-to-charge ratio used to pay cost outlier payments is changed as a result
of the amended cost report, no retroactive adjustments are made to cost outlier
payments using the amended cost-to-charge ratio. After the amended desk review
is completed and the thirty (30) day appeal option has been exhausted the new
inpatient cost-to-charge ratio is entered into the Mississippi Medicaid
Management Information System and is in effect from the date of entry through
the end of the current reimbursement period.
2. Out-of-state hospitals are reimbursed
under the APR-DRG payment methodology. The inpatient cost-to-charge ratios
(CCRs) used to pay cost outlier payments for each out-of-state hospital are set
using the Federal Register, that applies to the federal fiscal year beginning
October 1 of each year, issued prior to the reimbursement period. The inpatient
CCR is calculated using the sum of the statewide average operating urban CCR
plus the statewide average capital CCR for each state.
3. A Mississippi facility which undergoes a
change of ownership must notify the Division of Medicaid in writing of the
effective date of the sale. The seller must file a final cost report with the
Division of Medicaid from the date of the last cost report to the effective
date of the sale. The filing of a final cost report may be waived by the
Division, if the cost report is not needed for reimbursement purposes. The new
owner must file a cost report from the date of change of ownership through the
end of the Medicare cost report year end. The new owner must submit provider
enrollment information required under the Division of Medicaid
policy.
4. The inpatient
cost-to-charge ratio, of the old owner is used to pay cost outlier payments for
the new owner. The new owner's inpatient cost-to-charge ratio used to pay cost
outlier payments is calculated for the first rate beginning October 1, for
which the new owner's cost report is available. There are no retroactive
adjustments to a new owner's inpatient cost-to-charge ratio used to pay cost
outlier payments.
5. New
Mississippi hospitals beginning operations during a reporting year must file an
initial cost report from the date of certification to the end of the cost
report year end. Each rate year the inpatient cost-to-charge ratio used to pay
outlier payments for each Mississippi hospital is grouped by bed class of
facilities and an average inpatient cost-to-charge ratio is determined for each
class. The initial inpatient cost-to-charge ratio used to pay cost outlier
payments to a new hospital will be the average inpatient cost-to-charge ratio
used for the bed class of Mississippi hospitals as of the effective date of the
Medicaid provider agreement until the inpatient cost-to-charge ratio is
recalculated based on the new hospital's initial cost report. There are no
retroactive adjustments to a new hospital's inpatient cost-to-charge ratio used
to pay cost outlier payments.
E. The Division of Medicaid reimburses for
Graduate Medical Education (GME). Payment schedules and calculations are
defined in Attachment 4.19-A of the Medicaid State Plan. The Division of
Medicaid does not reimburse for indirect GME costs. To qualify for GME
payments, Mississippi hospitals must meet the following criteria:
1. Be located in the state of
Mississippi.
2. Have accreditation
from the Accreditation Council for Graduate Medical Education (ACGME) or the
American Osteopathic Association (AOA) at the beginning of the state fiscal
year in order to qualify for the quarterly payments during the payment
year.
3. Have a Medicare approved
teaching program for direct GME costs.
4. Be eligible for Medicare GME
reimbursement.
5. Render services
on the campus of the teaching hospital or at a participating hospital site.
a) The participating site must be listed on
the ACGME website.
b) If the
participating site uses the teaching hospital's ACGME accreditation, there must
be a current affiliation agreement in place with the teaching hospital as of
July 1st of the payment year.
c) Only the teaching hospital or the
participating hospital site is eligible for GME reimbursement.
6. Have full-time equivalents
(FTEs) reported on Worksheet E-4, line 6, line 15 or line 16 columns 1 and 2 of
the most recent Medicare cost report filed with DOM for the calendar year
immediately prior to the beginning of the fiscal year for
sponsoring/participating hospitals.
7. Any hospital which is a newly accredited
sponsoring/participating hospital or is within the five (5) year resident cap
building period for the newly accredited sponsoring/participating hospital must
be in operation as of July 1 of the payment year and must submit:
a) Documentation of accreditation,
b) Medicare's most recent interim rate
letter, and
(1) The number of residents used
to calculate medical education payments during cap building years will be the
number of FTEs as reported on the Medicare interim rate letter.
(2) If the number of FTEs reported on the
Medicare interim rate letter does not cover the entire cost reporting period,
the reported FTEs will be annualized and used to calculate medical education
payments,
c) Start date
of the GME accredited sponsoring/participating hospital prior to the July 1
calculation of the payments.
8. Has GME eligibility determined each year
with the submission of the following annually:
a) Documentation of accreditation,
b) Medicare's most recent interim rate
letter,
c) Number of filled
resident positions,
d) Start date
of the GME program prior to the July 1 calculation of the payments,
and
e) Documentation that the
program was in operation as of July 1 of the payment year.
F. Outpatient services provided to
a beneficiary by the admitting hospital, or by an entity wholly owned or
operated by the admitting hospital, within the three (3) days prior to an
inpatient hospital admission that are related to the reason for the inpatient
hospital stay must be included in the APR-DRG payment for the inpatient
hospital stay. This is referred to as the three (3) day payment window rule.
1. The inpatient hospital claim must include
the following:
a) Diagnostic services provided
to a beneficiary within three (3) days prior to and including the date of an
inpatient hospital admission, and
b) Therapeutic (non-diagnostic) services
related to an inpatient hospital admission and provided to a beneficiary within
three (3) days prior to and including the date of the inpatient
admission.
2. If
outpatient services are provided more than three (3) days prior to admission to
a beneficiary by the admitting hospital, or an entity wholly owned or operated
by the admitting hospital, and the outpatient service dates span to days
outside of the three (3) day window the hospital must:
a) Split bill for the outpatient services
provided outside of the three (3) day window on a claim separate from the
inpatient claim, and
b) Include the
outpatient services provided that are related to the reason for the inpatient
hospital stay within the three (3) day window on the inpatient hospital
claim.
3. Maintenance
renal dialysis services are excluded from the three (3) day window payment
rule.
4. Although the Division of
Medicaid's policy is based on Medicare policy, the Division of Medicaid's
policy applies if there is a difference.
42 U.S.C.
§ 1395f; 42 C.F.R. § 447.325; Miss. Code Ann. §§
43-13-121,
43-13-117; SPA 20-0018; SPA 19-0019.
