Wiki In-Patient outlier claims

[mevans303]

Hello, I am new to in-patient facility coding and would like some insight on understanding why our facility is not getting outlier payments above the DRG amount. I have studied the multitude of information on this but still am not clear.
Example: If covered charges exceed the outlier threshold amount, and there is a value code of 80 with 4 days in form locator 40. the patient stay was 4 days. Should the hospital expect outlier reimbursement? Any insight would be very much appreciated!

 

[Leandra]

If the facility and payer have a contract stating facility should be paid DRG outlier then that information/detail should be called out in the contract

 

[sls314]

Outlier methodology depends on the payer. If it is a commercial plan, the outlier methodology should be spelled out in the payer contract. (It won't necessarily be the same as CMS methodology.)

Medicare and Medicare Advantage plans will use the IPPS methodology defined by CMS.

Medicaid and Managed Medicaid plans will follow the outlier methodology as defined by the state-specific Medicaid rules.

Things to remember, especially for commercial plans...

Carveout reimbursement will often be excluded from the outlier threshold. (For example, if the payer contract pays you separately for implants in Revenue Code 278 and high-cost drugs in Revenue Code 636, then often those carved-out revenue codes will not count towards the outlier threshold.)

Pre-payment charge audits: Check to see if the payer did a pre-payment audit of the itemized statement and documentation. Payers like to try doing this, because often they can get out of paying outlier reimbursement that way.