#1 You're an inpatient coder in a hospital. You've just coded a Medicare Part A record with a diagnosis-related group (DRG) reinbursement of $12,000. You notic in the hospital's computer billing system that the patient's charges are $19,500. That's $7,500 more than the hospital will be reinbursed. How does the difference between the charges and the DRG reinbursement become resolved? #2 Yo're reviewing reinbursement for a Medicare surgical craniotomy case. The case falls into DRG1, which has a relative weight of 3.09070 and a geometric mean lenth of stay of 6.3. The hospital's current standard reinbursement rate is $1500. Calculate the DRG reinbursement for this case. Thankyou inadvance for your help with these question.
#1 The difference between the charges and the DRG reimbursement in a Medicare Part A record usually gets resolved through a process known as "payment reconciliation." Here's how it generally works:
1. The hospital bills the patient for the total charges of $19,500.
2. The hospital also submits a claim to Medicare, indicating that the patient falls into a specific DRG with a reimbursement rate of $12,000.
3. Medicare reviews the claim and determines the actual payment amount based on the DRG reimbursement rate, any applicable adjustments, and other factors.
4. Medicare then pays the hospital directly, typically through Electronic Funds Transfer (EFT) or via a check, for the determined reimbursement amount of $12,000.
5. The hospital receives the payment from Medicare and applies it to the patient's account, resulting in a credit of $12,000.
6. The remaining balance of $7,500 ($19,500 - $12,000) is typically written off or absorbed by the hospital as a contractual adjustment or bad debt.
It's important to note that the specific payment reconciliation process can vary depending on the hospital's contracts with Medicare and other factors. So, it's always a good idea to consult with the hospital's billing department or a reimbursement specialist for the accurate and detailed process in a specific scenario.
#2 To calculate the DRG reimbursement for a Medicare surgical craniotomy case falling into DRG1, you can use the following formula:
DRG Reimbursement = (DRG Relative Weight) x (Hospital's Standard Reimbursement Rate)
Given the information you provided:
- DRG1's relative weight is 3.09070
- The hospital's standard reimbursement rate is $1,500
Calculating the DRG reimbursement:
DRG Reimbursement = 3.09070 x $1,500
= $4,636.05
So, the DRG reimbursement for this case would be approximately $4,636.05.
Note: Please keep in mind that medical billing and reimbursement can be complex, and the specific calculations may vary depending on factors such as geographical location, contractual agreements, and specific insurance policies. It's always advisable to consult with billing specialists or professionals in the healthcare industry for precise calculations in a particular scenario.