Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1163 - INPATIENT HOSPITAL SERVICES
Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM
PAYMENT FOR HOSPITAL SERVICES
Section 1163.56 - Outliers

Universal Citation: 55 PA Code ยง 1163.56

Current through Register Vol. 54, No. 44, November 2, 2024

(a) Except for DRGs specified under subsection (f), the Department will pay the hospital an amount in addition to the DRG payment for the hospital stay under subsection (d) if:

(1) The hospital stay qualifies as a day outlier under subsection (b).

(2) The payment conditions in subsection (c) are met.

(b) Except for DRGs specified under subsection (f), to qualify as a day outlier the inpatient hospital stay of an MA recipient shall exceed the trim point for the DRG. The trim point for a DRG is the lesser of one of the following:

(1) Twenty days above the geometric mean length of stay for the DRG.

(2) 1.94 standard deviations above the geometric mean length of stay for the DRG.

(c) To receive payment for a case identified as a day outlier, the following conditions shall be met:

(1) The hospital shall submit a copy of the patient's medical record with the invoice submitted for payment.

(2) The Department will certify the medical necessity of all days of care provided.

(3) The hospital stay shall qualify as a day outlier under the criteria in subsection (b) based on the medically necessary days certified by the Department.

(d) The Department will determine the outlier payment amount for a day outlier by:

(1) Determining a per diem amount for the DRG by dividing the hospital's payment amount for the DRG by the Statewide average length of stay for the DRG.

(2) Multiplying the per diem amount for the DRG by 60% to establish the marginal per diem rate for the DRG.

(3) Subtracting the number of days at the trim point for the outlier as identified in subsection (b) from the actual number of inpatient hospital days to establish the number of outlier days.

(4) Multiplying the amount determined under paragraph (2) by the number of days determined in paragraph (3) to establish the outlier payment amount.

(e) If a hospital is requesting a day outlier payment, the Department will approve or disapprove the inpatient days based on the medical necessity of the days. Only the approved inpatient days are used in determining the outlier status of the inpatient case.

(f) The Department will pay an amount in addition to the DRG payment for the hospital stay under subsection (i) if:

(1) The hospital stay qualifies as a cost outlier under subsection (g).

(2) The payment conditions in subsection (h) are met.

(3) The hospital stay groups into DRG 385-390, 456-460 or 472, or is a major burn claim or abnormal newborn claim which would have grouped into one of those DRGs under grouper version 7.

(g) A DRG specified under subsection (f) qualifies as a cost outlier if the cost of the case exceeds 150% of the hospital's DRG base payment. The Department will calculate the cost of the case by multiplying the charges indicated on the invoice by the hospital's cost-to-charge ratio.

(h) To receive payment for a case identified as a cost outlier, the following conditions shall be met:

(1) The hospital shall submit a copy of the patient's medical record with the invoice submitted for payment.

(2) The Department will certify the medical necessity of the days of care and the services provided.

(3) The hospital stay shall qualify as a cost outlier under subsection (g) based on the medically necessary days and services certified by the Department.

(i) The outlier payment amount for a cost outlier is 100% of the cost of the case as certified under subsection (h) that exceeds 150% of the hospital's base payment amount for the DRG.

(j) If a hospital is requesting a cost outlier payment, the Department will approve or disapprove the inpatient services based on the medical necessity of the services. Only the cost of approved services is used in determining the cost outlier status of the inpatient case.

The provisions of this §1163.56 amended under sections 201, 403 and 443.1(1) of the Public Welfare Code (62 P. S. §§ 201, 403 and 443.1(1)).

This section cited in 55 Pa. Code § 1163.51 (relating to general payment policy); 55 Pa. Code § 1163.57 (relating to payment policy for readmissions); 55 Pa. Code § 1163.59 (relating to noncompensable services, items and outlier days); 55 Pa. Code § 1163.65 (relating to payment for out-of-State hospital services); 55 Pa. Code § 1163.78a (relating to review requirements for day outliers); and 55 Pa. Code § 1163.126 (relating to computation of hospital specific base payment rates).

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