Current through Register Vol. 41, No. 3, September 23, 2024
A. An outlier operating payment shall be made
for outlier cases. This payment shall be added to the operating payments
determined in
12VAC30-70-231 and
12VAC30-70-251. Eligibility for
the outlier operating payment and the amount of the outlier operating payment
shall be determined as follows:
1. The
hospital's adjusted operating cost for the case shall be estimated. This shall
be equal to the hospital's total charges for the case times the hospital's
operating cost-to-charge ratio, as defined in subsection C of
12VAC30-70-221, times the
adjustment factor specified in
12VAC30-70-331 B.
2. The adjusted outlier operating fixed loss
threshold shall be calculated as follows:
a.
The outlier operating fixed loss threshold shall be multiplied by the statewide
average labor portion of operating costs, yielding the labor portion of the
outlier operating fixed loss threshold. Hence, the nonlabor portion of the
outlier operating fixed loss threshold shall constitute one minus the statewide
average labor portion of operating costs times the outlier operating fixed loss
threshold.
b. The labor portion of
the outlier operating fixed loss threshold shall be multiplied by the
hospital's Medicare wage index, yielding the wage adjusted labor portion of the
outlier operating fixed loss threshold.
c. The wage adjusted labor portion of the
outlier operating fixed loss threshold shall be added to the nonlabor portion
of the outlier operating fixed loss threshold, yielding the wage adjusted
outlier operating fixed loss threshold.
3. The hospital's outlier operating threshold
for the case shall be calculated. This shall be equal to the wage adjusted
outlier operating fixed loss threshold times the adjustment factor specified in
12VAC30-70-331 B plus the
hospital's operating payment for the case, as determined in
12VAC30-70-231 or
12VAC30-70-251.
4. The hospital's outlier operating payment
for the case shall be calculated. This shall be equal to the hospital's
adjusted operating cost for the case minus the hospital's outlier operating
threshold for the case. If the difference is less than or equal to zero, then
no outlier operating payment shall be made. If the difference is greater than
zero, then the outlier operating payment shall be equal to the difference times
the outlier adjustment factor.
B. The outlier operating fixed loss threshold
shall be recalculated using base year data when the DRG payment system is
recalibrated and rebased. The threshold shall be calculated so as to result in
an expenditure for outlier operating payments equal to 5.1% of total operating
payments, including outlier operating payments, for DRG cases. The methodology
described in subsection A of this section shall be applied to all base year DRG
cases on an aggregate basis, and the amount of the outlier operating fixed loss
threshold shall be calculated so as to exhaust the available pool for outlier
operating payments.
§§ 32.1-324 and 32.1-325 of the Code of
Virginia.
