Current through Register Vol. 54, No. 44, November 2, 2024
(a) A hospital's base payment rate, which is
exclusive of capital, will be the amount determined under this
section.
(b) The Department will
determine a hospital's case mix adjusted cost per case by first identifying the
hospital's reported MA allowable costs from the hospital's base year Fiscal
Year 1986-87 Cost Report (MA 336) and from this amount subtracting each of the
following items:
(1) The MA portion of the
hospital's inpatient costs for direct medical education.
(2) The MA portion of the hospital's
allowable net inpatient costs for depreciation and interest for buildings and
fixtures.
(c) The
Department will determine a hospital's adjusted net MA allowable cost by
adjusting the inpatient acute care MA cost determined under subsection (b) to
account for differences between the hospital's reported MA days for the base
year and the MA days contained in the Department's claims database for the base
year. The Department will determine the adjustment by dividing the hospital's
MA claims days by the hospital's reported MA days and multiplying this ratio by
the hospital's adjusted inpatient acute care MA costs determined under
subsection (b).
(d) The Department
will determine each hospital's net cost to be used in payment rate calculations
by subtracting from the net MA allowable costs determined under subsection (c),
the following costs determined using the Department's paid claims database for
the base fiscal year:
(1) The cost outlier
portion of costs for claims that qualify as cost outliers under §
1163.56 (relating to
outliers).
(2) Day outlier portion
of costs for claims that qualify as day outliers under §
1163.56.
(3) The costs of transfer
claims except for DRGs 385 and 456.
(4) The costs of the hospital's claims which
are no longer paid as inpatient claims.
(5) The cost of psychiatric claims exclusive
of the first 2 days of the hospital stay, for hospitals without a distinct part
psychiatric unit enrolled in the MA Program.
(6) The full costs of psychiatric claims, for
hospitals with a distinct part psychiatric unit enrolled in the MA
Program.
(7) The costs of drug and
alcohol claims exclusive of the first 2 days of the hospital stay, for
hospitals that are not approved for drug and alcohol detoxification
services.
(8) The full costs of
drug and alcohol claims, for hospitals with a distinct part drug and alcohol
unit enrolled in the MA Program.
(e) The Department will reduce a hospital's
net cost determined under subsection (d) by the 1.77% overreporting
factor.
(f) The Department will
determine a hospital's average cost per case for the base year by dividing the
hospital's costs as established under subsection (e) by the adjusted number of
MA cases for that year. The Department will determine the adjusted number of MA
cases by:
(1) Identifying the hospital's total
number of MA claims in the base year using the Department's paid claims
database for the base fiscal year.
(2) Subtracting from the amount in paragraph
(1) each of the following items:
(i) The
number of claims identified for psychiatric services for hospitals with
distinct part psychiatric units enrolled in the MA Program.
(ii) The number of claims identified for drug
and alcohol treatment services for hospitals with distinct part drug and
alcohol units enrolled in the MA Program.
(iii) The number of claims involving patient
transfers, except for transfers occurring in DRGs 385 and 456.
(iv) The number of claims identified
involving MA cases which were eligible for Medicare reimbursement.
(v) The number of claims which are no longer
paid as inpatient claims.
(g) The Department will standardize a
hospital's average cost per case to account for case mix by dividing the
hospital's average cost per case as determined under subsection (f) by its case
mix index. The resultant value will be referred to as the base year case mix
adjusted cost per case. The Department will determine the hospital's case mix
index by:
(1) Identifying the total number of
MA DRG cases for the hospital for the base year from the Department's paid
claims data.
(2) Summing the
relative values of each of the cases identified under paragraph (1) to
establish an aggregate relative value amount for the hospital.
(3) Dividing the hospital's aggregate
relative value amount determined under paragraph (2) by the number of MA cases
determined under paragraph (1) to establish an average relative value or case
mix index for the hospital.
(h) Except as specified in subsections (i)
and (j), the Department will establish base rates for Fiscal Years 1993-94 and
1994-95, by trending forward each hospital's base year case mix adjusted cost
per case by use of the following inflation factors:
(1) 4.5% to account for Fiscal Year 1987-88
inflation.
(2) 5.6% to account for
Fiscal Year 1988-89 inflation.
(3)
5.0% to account for Fiscal Year 1989-90 inflation.
(4) 5.3% to account for Fiscal Year 1990-91
inflation.
(5) 5.2% to account for
Fiscal Year 1991-92 inflation.
(6)
4.6% to account for Fiscal Year 1992-93 inflation.
(7) 4.3% to account for Fiscal Year 1993-94
inflation, to be applied as follows:
(i)
Hospitals that qualified for a volume or rural disproportionate share rate
enhancement for Fiscal Year 1992-93 will receive the 4.3% inflation factor
effective July 1, 1993.
(ii)
Hospitals that did not qualify for a volume or rural disproportionate share
rate enhancement for Fiscal Year 1992-93 will receive the 4.3% inflation factor
effective January 1, 1994.
(8) For Fiscal Year 1994-95, effective
January 1, 1995, acute care general hospitals will receive an inflation factor
equal to the prospective payment system type hospital market basket moving
average inflation factor published by DRI/McGraw-Hill in the fourth calendar
quarter of 1993 for the second calendar quarter of 1995.
(i) The Department will establish base rates
as follows for hospitals that changed ownership during the period July 1, 1986,
through June 30, 1993:
(1) For a hospital that
elected to have its rates rebased upon change of ownership, the base rate for
Fiscal Year 1993-94 will be the base rate effective June 30, 1993, trended
forward using applicable inflation factors.
(2) For a hospital that elected not to have
its rate rebased upon change of ownership, the base rate for Fiscal Year
1993-94 will be the rate calculated under subsections (a)-(h) for the prior
entity.
(j) Rates
established under subsections (a)-(i) will be limited as follows:
(1) For Fiscal Year 1993-94, a hospital's
base rate may not exceed $6,244.
(2)
For Fiscal Year 1994-95, a hospital's base rate may not exceed $6,244 increased
effective January 1, 1995, by the inflation factor described under subsection
(h)(8).
The provisions of this §1163.126 issued under sections 201
and 443.1(1) of the Public Welfare Code (62 P. S.
§§
201 and
443.1(1)).
This section cited in 55 Pa. Code §
1163.52 (relating to prospective
payment methodology).
