California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51555 - Peer Group Specific Administrative Adjustment Issue

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Differences in case mix (including
					 outliers) between the provider and other providers in its peer group shall be
					 determined for the PGRPDL using the following formula, but subject to reduction
					 for overlapping issues as specified in Section (d) below:
MARD=PGL * CMA
Where: MARD=Maximum Allowable Rate per Discharge under
						the PGRPDL.
CMA=Case Mix Adjustment, which is the providers case mix
						index divided by the peer group 60th percentile case mix index.
PGL=Peer Grouping reimbursement Limit per discharge (60th
						percentile ARPD for the peer group if no adjustments have been made).
(1) Case mix indexes shall be based on DRGs
					 and shall be computed using OSHPD patient discharge data for providers.
					 Providers with an ARPD CMAF shall use data they are required to supply for the
					 ARPD CMAF. However, the set of DRG weights used must be consistent for all
					 providers in the peer group and shall be determined by the Department for each
					 FPE.
(2) Providers shall be allowed
					 to submit more accurate patient discharge data for their hospital. Any such
					 patient discharge data must be submitted with the AAR. The data cannot be used
					 until it is verified by the Department. The Department shall not accept data
					 that it determines may not accurately reflect the provider's Medi-Cal
					 patients.
(3) If OSHPD patient
					 discharge data does not correspond with all provider's FPE, the closest FPE
					 shall be used. Indices will be developed for a calendar year and for a July 1 -
					 June 30 FPE. The period which most closely corresponds to the providers FPE
					 shall be used. Calendar year data shall be used for FPEs from October 1 through
					 March 31 inclusive. July 1 through June 30 fiscal period data shall be used for
					 all other FPEs.
(4) CMAs may be
					 applied to any provider with a case mix index greater than the 60th percentile
					 case mix index of its peer group.
(5) In addition to case mix relief, a
					 provider shall be granted relief for outliers if the provider's outlier relief
					 per discharge is greater than the computed 60th percentile outlier relief per
					 discharge for all providers in the provider's peer group. The methodology used
					 shall be as follows:
(A) Using OSHPD patient
					 discharge data, and Medicare criteria for DRG outlier relief as specified in 42
					 CFR, Part 412 , compute the total outlier relief for all providers in each peer
					 group (using the same formula as listed in Section
					 51551 -ARPD case mix and
					 outliers). However, the cost outlier cutoff shall not vary within any one FPE
					 worth of data.
(B) Convert the
					 results under (1) above to outlier relief per- Medi-Cal discharge.
(C) Align the results of (B) above, in order
					 from lowest at the bottom up to the highest at the top, and by counting up from
					 the bottom to the n + 1 provider (n = # of providers in the peer group),
					 compute the 60th percentile outlier relief per discharge for each peer
					 group.
(D) If the requesting
					 providers's outlier relief per discharge is greater than the 60th percentile
					 outlier relief per discharge, the provider's MARD shall be increased by the
					 difference of the two figures.
(6) These formulas shall be subject to the
					 following limitations:
(A) Only those
					 providers with 30 or more Medi-Cal discharges shall be included in the
					 calculation of the 60th percentile outlier and case mix index per discharge.
					 However, providers with under 30 Medi-Cal discharges may still receive relief
					 using the formulas in this Section.
(B) Providers whose Medi-Cal discharge count
					 per their OSHPD patient discharge data has more than a 50 percent variance from
					 the appropriate Medi-Cal discharge figure from the cost report, after adjusting
					 for well newborns who are included in the OSHPD patient discharge data but not
					 counted as Medi-Cal discharges, shall be excluded from the 60th percentile
					 calculation. Cost report figures shall be adjusted to estimate the calendar or
					 fiscal period OSHPD data.
(C) If
					 the provider requesting outlier relief has more than a 10 percent variance in
					 Medi-Cal discharge figures (OSHPD patient discharge data vs. Medi-Cal cost
					 report), or under 30 Medi-Cal discharges, the provider shall be required to
					 submit its own data for use in the calculation. Such data must be for all
					 Medi-Cal patients and include the patient's last name, ICD-9 primary diagnosis
					 code, admission data, discharge date, DRG number, charges, patient's age, and
					 OSHPD disposition code. The list shall be in admission date order.
(D) Providers may submit additional data to
					 replace the OSHPD data. Any such data must be supplied with the AAR. Providers
					 must supply a list in admission date order, containing each Medi-Cal patient's
					 last name, ICD-9 code, admission date, discharge date, DRG number, charges,
					 patient's age, and OSHPD disposition code.
(7) For noncontracting hospitals that do not
					 keep a patient for the full episode of care, the CMA formula will be modified
					 by one of the following formulas:
(A) Use only
					 40 percent of the appropriate DRG case mix weight for patients treated by
					 noncontract hospitals, or
(B)
1. Track each patient's record to the
					 contract hospital they were transferred to, and
2. Sum the charges from both providers,
					 and
3. Apply the percent of total
					 charges from the noncontract hospital to the DRG
					 weight.