How is Medicare DRG payment calculated?
The MS-DRG payment for a Medicare patient is determined by multiplying the relative weight for the MS-DRG by the hospital’s blended rate: MS-DRG PAYMENT = RELATIVE WEIGHT × HOSPITAL RATE.
How does the DRG payment system work?
In general, a DRG payment covers all charges associated with an inpatient stay from the time of admission to discharge. The DRG includes any services performed by an outside provider. Claims for the inpatient stay are submitted and processed for payment only upon discharge.
How are DRG rates determined?
Under the IPPS, DRG per-discharge payment rates are based on patients’ clinical conditions (diagnoses) and the procedures furnished by the hospital during the stay. The beneficiary’s principal diagnosis and up to eight secondary diagnoses that indicate comorbidities and complications will determine the DRG assignment.
What is a DRG outlier payment?
Outlier payments compensate hospitals paid on a fixed amount per “diagnosis related group” discharge with extra dollars for patient stays that substantially exceed the typical requirements for patient stays in the same DRG category.
What is DRG pricing?
The DRG prices represent the relative costliness of inpatient hospital services provided to Medicare beneficiaries. Since the implementation of this prospective payment system (PPS), the DRG prices have been based on both estimated costs and charges.
What is a DRG code?
Diagnosis-related group (DRG) is a system which classifies hospital cases according to certain groups,also referred to as DRGs, which are expected to have similar hospital resource use (cost). They have been used in the United States since 1983.
What is DRG creep?
1. Refers to the practices of healthcare providers that intentionally regroup patients according to more resource intensive DRG classifications in order to increase hospital income. Examples are ‘upgrading’ and ‘upcoding’.
What is a cost outlier?
Cost outlier — an inpatient hospital discharge that is extraordinarily costly. To qualify for outlier payment, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments to qualify for outliers).
What is the portion of the medical fees that the patient needs to pay at the time of services called?
Week 5
| Question | Answer |
|---|---|
| The portion of the medical fees that the patient needs to pay at the time of services is called: | co-pay |
| The largest medical insurance program in the United States is: | Medicare |
| The cost that patients must pay each month (sometimes provided by their employers) is called the: | premium |
How are DRG payments calculated?
basic DRG payment rate. The payment that a hospital receives for a Medicare patient in a particular diagnosis-related group (DRG); the rate is calculated by adjusting the standardised amount to reflect wages and non-wage cost-of-living differences in the hospital’s geographic area and the cost of the DRG.
What does DRG stand for?
DRG stands for Diagnosis Related Group (Medicare reimbursement model) Suggest new definition. This definition appears very frequently and is found in the following Acronym Finder categories: Military and Government. Organizations, NGOs, schools, universities, etc.
How does DRG payment work?
In general, a DRG payment covers all charges associated with an inpatient stay from the time of admission to discharge. The DRG includes any services performed by an outside provider. Claims for the inpatient stay are submitted and processed for payment only upon discharge.
How is a DRG determined?
DRGs are assigned by a “grouper” program based on ICD (International Classification of Diseases) diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities. DRGs have been used in the US since 1982 to determine how much Medicare pays the hospital for each “product”,…