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25.2.2.4 Outliers
TMHP makes outlier payment adjustments to DRG hospitals for admissions that meet the criteria for exceptionally high costs or exceptionally long lengths of stay for clients younger than 21 years of age as of the date of the inpatient admission. If a client's admission qualifies for both a day and a cost outlier, the outlier resulting in the higher payment to the hospital is paid. The R&S report reflects the outlier reimbursement payment and defines the type of outlier paid.
Day Outliers
The following criteria must be met to qualify for a day outlier payment. Inpatient days must exceed the DRG day threshold for the specific DRG. Additional payment is based on inpatient days that exceed the DRG day threshold multiplied by 70 percent of the per diem amount of a full DRG payment. The per diem amount is established by dividing the full DRG payment amount by the arithmetic mean length of stay for the DRG.
Hospitals should use the following formula to calculate the day outliers. To calculate the day outlier payment amount, the number of outlier days must first be determined:
Number of Days Allowed-DRGs Threshold = Outlier Days
Cost Outliers
To establish a cost outlier, TMHP determines the outlier threshold by using the full DRG payment amount multiplied by 1.5 or an amount determined by selecting the lesser of the universal mean of the current base year data multiplied by 11.14 or the hospital's SDA multiplied by 11.14. The calculation that yields the amount is used in calculating the actual cost outlier payment. The outlier threshold is subtracted from the amount of reimbursement for the admission established under TEFRA principles, and the remainder multiplied by 70 percent to determine the actual amount of the cost outlier payment.
Hospitals should use the following formulas to calculate the day outliers for dates of admission on or after September 1, 2002. Effective September 1, 2002, (date of admission) the Universal Mean is $3,328.89.
To calculate the cost outlier amount, the cost threshold must first be determined. Three calculations and two comparisons are necessary:
A) |
11.14 x Universal Mean ($3,328.89) = $37,083.83 |
B) |
11.14 x SDA = _____________________Comparison 1: Take lesser of number A or B. |
C) |
1.5 x DRG Relative Weight X SDA = __________________ Comparison 2: Greater of number C and Comparison 1 is the cost threshold |
Allowed amount x reimbursement rate = ______________
Result of A minus cost threshold = ___________________
Result of B x0.70 = cost outlier amount
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