What is YOUR Hospital DRG?

“Part 2 deals with the $11,376.32 loss to Harrison after two insurance companies paid $1,100.00 and $5,109.58.
How long can any business survive if they are compelled to absorb such losses?”

I discovered answers from Harrison’s new Patient Financial Supervisor, Christine Warner. Additionally, I learned that Harrison offers deep discounts, and has other programs in place via a “Contractual Allowance.”
Contact them and see what they can do for you.

According to Christine Warner, my DRG is 300 thus accounting for their low Medicare payment reimbursement.

The Tricare reimbursement is based on the Medicare rate of return and other insurances may pay more.

Medicare will also pay more than the hospital charges for other patients with lower numbers helping offset the high numbered patients like me.

As more baby bloomers enter Medicare, Harrison and other hospitals will be hard pressed to cut costs….and, I hope, get more into preventative issues and using patients to help each other.

Something I think would help cut future costs and that is to educate the patient by was of a genetic support group, meeting once a week. The issues are much the same for patients with multiple medical conditions and the emphasis should be on nutrition, and physical fitness. We could invite speakers from around the county…even from among the patients.

I have found a similar mindset among the best professionals I have met and been challenged by all. Patients teach each other and most medical professionals would be happy to help the cause of better health.

To name a few: Yvonne Kerstad with Janice McFarland’s, Body ReForm, Silverdale’s Pilates and Physical Therapy Studio. Yvonne altered many of the exercises to suit my physical condition Yvonne can also address firsthand, exercising pre and post around a hip replacement.

Anna Marx, Kitsap Physical Therapy, Silverdale, is another who thinks outside the circle. She proved to me that I COULD increase the range of motion of my left hip. Additionally, Sara is a recumbent bike rider and entered in the 2010 Seattle – Portland ride

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“Medicare Prospective Payment System

Introduction

The Medicare Prospective Payment System (PPS) was introduced by the federal government in October, 1983, as a way to change hospital behavior through financial incentives that encourage more cost-efficient management of medical care. Under PPS, hospitals are paid a pre-determined rate for each Medicare admission. Each patient is classified into a Diagnosis Related Group (DRG) on the basis of clinical information. Except for certain patients with exceptionally high costs (called outliers), the hospital is paid a flat rate for the DRG, regardless of the actual services provided.

Each Medicare patient is classified into a Diagnosis Related Group (DRG) according to information from the Medical Record that appears on the bill:

• Principal Diagnosis (why the patient was admitted)
• Complications and Comorbidities (CCs – other secondary diagnoses)
• Surgical Procedures
• Age
• Gender
• Discharge Disposition (routine, transferred, or expired)

How it Works

Diagnoses and procedures must be documented by the attending physician in the patient�s medical record. They are then coded by hospital personnel using ICD-9-CM nomenclature. This is a numerical coding scheme of over 13,000 diagnoses and 5,000 procedures.

The coding process is extremely important since it essentially determines what DRG will be assigned for a patient. Coding an incorrect principal diagnosis or failing to code a significant secondary diagnosis can dramatically effect reimbursement.

There are over 490 DRG categories defined by the Centers for Medicare and Medicaid Services (CMS, formerly known as HCFA). Each category is designed to be “clinically coherent.” In other words, all patients assigned to a DRG are deemed to have a similar clinical condition. The Prospective Payment System is based on paying the average cost for treating patients in the same DRG.

Each year CMS makes technical adjustments to the DRG classification system that incorporate new technologies (e.g. laparoscopic procedures) and refine its use as a payment methodology. CMS also initiates changes to the ICD-9-CM coding scheme. The DRG assignment process is computerized in a program called the grouper that is used by hospitals and fiscal intermediaries.

Each year CMS also assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG with a weight of 2.0000 means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average.

Top 10 DRGs
The ten highest volume Medicare DRGs represent about 30% of total Medicare patients. Each of these higher volume DRGs represent from about 2% to 6% of total Medicare volume.

DRG DRG Description % Total Rel Wt

1 127 Heart Failure & Shock 5.99 1.0234
2 089 Simple Pneumonia & Pleurisy Age>17 w/CC1 3.85 1.1447
3 014 Specific Cerebrovascular Disorders except TIA 3.18 1.2056
4 430 Psychoses 3.18 0.9153
5 088 Chronic Obstructive Pulmonary Disease 3.11 1.0067
6 209 Major Joint & Limb Reattachment Procedures, Lower Extremity 2.78 2.3491
7 140 Angina Pectoris 2.33 0.6241
8 182 Esophagitis, Gastroent & Misc Digest Disorders Age>17 w/CC1 2.09 0.7617
9 174 G.I. Hemorrhage w/CC1 2.07 0.9657
10 296 Nutritional & Misc Metabolic Disorders Age>17w/CC1 1.93 0.9313

Note: “CC” signifies a significant complication or comorbidity
Source: Health Care Financing Administration, 1994.
DRG-based Payments
The DRG payment for a Medicare patient is determined by multiplying the relative weight for the DRG by the hospital�s blended rate:…”
DRG PAYMENT = WEIGHT x RATE

Read more: http://pugetsoundblogs.com/copd-and-other-stuff/2010/06/26/harrisons-strength-is-in-her-volunteers-and-staff/#ixzz0s42zrGV0

http://www.ahd.com/pps.html

More later… Sharon O’Hara