Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-460 - Hospital settlement

Current through Register Vol. 40, No. 24, July 15, 2024
A. During
					 the transition period claims will be processed and tentative payment made using
					 per diem rates. Settlements will be carried out to ensure that the correct
					 blend of DRG and per diem-based payment is received by each general acute care
					 and rehabilitation hospital and to settle reimbursement of pass-through costs.
					 There shall be no settlement of freestanding psychiatric facilities licensed as
					 hospitals except with respect to disproportionate share hospital (DSH) payment,
					 if necessary (see
					 12VAC30-70-301 E).
B. The transition blend percentages which
					 determine the share of DRG system and of revised per diem system reimbursement
					 that is applicable in a given period shall change with the change of the state
					 fiscal year, not the hospital fiscal year.
C. If a hospital's fiscal year does not end
					 June 30, its first year ending after June 30, 1996, contains one or more months
					 under the previous methodology, a "split" settlement shall be done of that
					 hospital's fiscal year. Services rendered through June 30, 1996, shall be
					 reimbursed under the previous reimbursement methodology and services rendered
					 after June 30, 1996, will be reimbursed as described in subsection G of this
					 section.
D. For cases subject to
					 settlement under the blend of DRG and per diem methodologies (cases with an
					 admission date after June 30, 1996), the date of discharge determines the year
					 in which any inpatient service or claim related to the case shall be settled.
					 This shall be true for both the DRG and the per diem portions of settlement.
					 Interim claims tentatively paid in one hospital fiscal year that relate to a
					 discharge in a later hospital fiscal year, shall be voided and reprocessed in
					 the latter year so that the interim claim shall not be included in the
					 settlement of the first year, but in the settlement of the year of discharge.
					 An exception to this shall be rehabilitation cases, the claims for which shall
					 be settled in the year of the "through" date of the claim.
E. A single group of cases with discharges in
					 the appropriate time period shall be the basis of both the DRG and the per diem
					 portion of settlement. These cases shall be based on claims submitted and, if
					 necessary corrected by 120 days after the providers FYE. Cases which are based
					 on claims that lack sufficient information to support grouping to a DRG
					 category, and which the hospital cannot correct, shall be settled for purposes
					 of the DRG portion of settlement based on the lowest of the DRG
					 weights.
F. Reimbursement for
					 services in freestanding psychiatric facilities licensed as hospitals shall not
					 be subject to settlement.
G. During
					 the transition period settlements shall be carried out according to the
					 following formulas.
1. Settlement of a
					 hospital's first fiscal year ending after July 1, 1996:
a. Operating reimbursement shall be equal to
					 the sum of the following:
(1) Paid days
					 occurring in the hospital's fiscal year before July 1, 1996, times the per diem
					 in effect before July 1, 1996.
(2)
					 Paid days occurring after June 30, 1996, but in the hospital fiscal year, that
					 are related to admissions that occurred before July 1, 1996, times the revised
					 system per diem that is effective on July 1, 1996.
(3) DRG system payment for DRG and
					 psychiatric cases admitted after June 30, 1996, and discharged within the
					 hospital fiscal year times 1/3.
(4)
					 DRG system payment for rehabilitation claims having a "from" date of July 1,
					 1996, or later and a "through" date within the hospital fiscal year times
					 1/3.
(5) Paid days from the cases
					 and claims in subdivisions 1 a (3) and (4) of this subsection, times the
					 revised system per diem that is effective on July 1, 1996, times 2/3.