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 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-221 - General

Current through Register Vol. 40, No. 24, July 15, 2024
A. Effective July
					 1, 2000, the prospective (DRG-based) payment system described in this article
					 shall apply to inpatient hospital services provided in enrolled general acute
					 care hospitals, rehabilitation hospitals, and freestanding psychiatric
					 facilities licensed as hospitals, unless otherwise noted.
B. The following methodologies shall apply
					 under the prospective payment system:
1. As
					 stipulated in
					 12VAC30-70-231,
					 operating payments for DRG cases that are not transfer cases shall be
					 determined on the basis of a hospital specific operating rate per case times
					 relative weight of the DRG to which the case is assigned.
2. As stipulated in
					 12VAC30-70-241,
					 operating payments for per diem cases shall be determined on the basis of a
					 hospital specific operating rate per day times the covered days for the case
					 with the exception of payments for per diem cases in freestanding psychiatric
					 facilities. Payments for per diem cases in freestanding psychiatric facilities
					 licensed as hospitals shall be determined on the basis of a hospital specific
					 rate per day that represents an all-inclusive payment for operating and capital
					 costs.
3. As stipulated in
					 12VAC30-70-251,
					 operating payments for transfer cases shall be determined as follows:
(i) the transferring hospital shall receive
					 an operating per diem payment, not to exceed the DRG operating payment that
					 would have otherwise been made and
(ii) the final discharging hospital shall
					 receive the full DRG operating payment.
4. As stipulated in
					 12VAC30-70-261,
					 additional operating payments shall be made for outlier cases. These additional
					 payments shall be added to the operating payments determined in subdivisions 1
					 and 3 of this subsection.
5. As
					 stipulated in
					 12VAC30-70-271,
					 payments for capital costs shall be made on an allowable cost basis.
6. As stipulated in
					 12VAC30-70-281,
					 payments for direct medical education costs of nursing schools and paramedical
					 programs shall be made on an allowable cost basis. For Type Two hospitals,
					 payment for direct graduate medical education (GME) costs for interns and
					 residents shall be made quarterly on a prospective basis, subject to cost
					 settlement based on the number of full-time equivalent (FTE) interns and
					 residents as reported on the cost report. Effective April 1, 2012, payment for
					 direct GME for interns and residents for Type One hospitals shall be 100% of
					 allowable costs.
7. As stipulated
					 in
					 12VAC30-70-291,
					 payments for indirect medical education costs shall be made quarterly on a
					 prospective basis.
8. As stipulated
					 in
					 12VAC30-70-301,
					 payments to hospitals that qualify as disproportionate share hospitals shall be
					 made quarterly on a prospective basis.