HIT 260 001 Fall 2020 IPPS Cost Outlier Calculations 20 points Due on 10/11/2020 via D2L Assignments Submission Folder Instructions: Review the hospital and claim information provided. Calculate the cost, MS-DRG payment, fixed-loss cost threshold, outlier add-on amount, total payment, and profit/loss amount for each claim for each provider using Excel formulas. The IPPS high-cost outlier threshold for FY 2020 is $26,473.00 Once you have completed the calculations, answer the corresponding questions. Hospital Information Hospital CCR Base Rate I Hospital A 0.429 $ 6,200.00 Hospital B 0.621 5,200.00 Hospital C 0.429 $ 8,000.00 Hospital D 0.621 $ 8,000.00 Claim Information Claim MS-DRG MS-DRG Description RW Total Charges 469 Major joint replacement or reattachment of lower extremity with MCC 3.1399 $ 50,995.12 2 003 ECMO or Tracheostomy with MV 96+ hours or PDX excluding face, moth & neck with major OR procedure 18.9539 $ 323,546.55 3 193 Simple pneumonia & pleurisy with MCC 1.3335 $ 75,654.25 A 159 Spinal fusion except cervical with MCC 5.852 $ 201,654.82 Hospital A Claim Cost MS-DRG Payment Fixed-loss cost threshold Outlier Amount Total Payment Profit/Loss 1 2 w TOTAL Profit/loss Hospital B Claim Cost MS-DRG Payment Fixed-loss cost threshold Outlier Amount Total Payment Profit/ Loss 1 2 3 TOTAL Profit/loss Hospital C Claim Cost MS-DRG Payment Fixed-loss cost threshold Outlier Amount Total Payment Profit/Loss\fIFro CUSt VUCIICI Calculation LAamPIC Example: This example shows how to calculate the outlier payment for an acute care inpatient admission. The IPPS high-cost outlier threshold for FY 2020 is $26,473.00. In order to determine if a case qualifies for an outlier payment you must calculate the MS-DRG payment for the encounter and calculate the cost for the encounter. Use the overall inpatient CCR for the facility in question. In this example the fully adjusted hospital specific base rate is $7,500.00. The CCR is .328. Outlier Formula: When the cost of an encounter is greater than the Fixed-loss cost threshold for the encounter then an outlier payment is warranted. The outlier payment is equal to 80% of the different between the cost of the encounter and the Fixed-loss cost threshold for the encounter. When the encounter is a burn MS-DRG, then the percentage is increased to 90%. lospital Happy Hospital Base Rate $7,500 AS-DRG 25 Craniotomy & endovascular intracranial procedures with MCC w 4.3945 charges $ 234,253.87 CR 0.328 OS 15 MS-DRG Reimbursement $ 32,958.75 Multiply the fully adjusted hospital specific base rate * the MS-DRG Relative Weight (RW) Cost of the encounter $ 76,835.27 Multiply the charges * the cost to charge ration (CCR) Profit/Loss $ (43,876.52) Subtract the cost of the encounter from the MS-DRG Reimbursement Fixed-loss cost threshold $ 59,431.75 Add the high cost outlier threshold ($26,473.00) to the MS-DRG Reimbursement amount Outlier is If the cost of the encounter is greater than the fixed-loss cost threshold then an outlier payment warranted is warranted. If the cost of the encounter is less than the fixed loss cost threshold then an outlier payment is not warranted. Difference between threshold and cost $ 17,403.52 Subtract the fixed-loss cost threshold from the cost of the encounter Outlier add-on payment $ 13,922.82 Multiply the difference by .80 (80%) Total payment for the encounter $ 46,881.57 Add the MS-DRG Reimbursement to the Outlier add-on payment Final Profit/Loss $ (29,953.70) Subtract the cost of the encounter from the Total payment for the encounter