You're an inpatient coder in a hospital. You've just coded a Medicare Part A record with a diagnosis-related group reimbursement of 12,000. You notice 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 reimbursed. How does the difference between the charges and the DRG reimbursement become resolved?
im so lost on this question.
I understand this question can be a bit confusing, but I'm here to help you understand it step by step.
In this scenario, you are an inpatient coder in a hospital, and you have just coded a Medicare Part A record with a diagnosis-related group (DRG) reimbursement of $12,000. However, you notice that the patient's charges in the hospital's computer billing system are $19,500, which is $7,500 more than what the hospital will be reimbursed.
To understand how this difference between the charges and the DRG reimbursement gets resolved, let's break it down:
1. Diagnosis-Related Group (DRG): DRGs are a classification system used by Medicare to categorize and reimburse patients for inpatient hospital care based on their diagnosis, procedures performed, age, and other factors. Each DRG has a set reimbursement rate associated with it.
2. Reimbursement: In this case, the reimbursement for the patient's DRG is $12,000. This means that the hospital will be paid $12,000 by Medicare for providing the necessary inpatient care for this particular diagnosis and treatment.
3. Patient's Charges: The patient's charges, as recorded in the hospital's computer billing system, amount to $19,500. This number represents the total cost incurred by the hospital for the patient's care, including services, procedures, medications, room charges, and other associated costs.
4. Difference: The difference between the patient's charges ($19,500) and the DRG reimbursement ($12,000) is $7,500. This difference arises due to additional costs incurred by the hospital that are not fully covered under the DRG reimbursement rate.
Resolution of the Difference:
To resolve this difference, there are a few possible scenarios:
1. Negotiations with Payers: The hospital can negotiate with the payer, such as Medicare, to review the charges and potentially increase the reimbursement based on specific justifications for the additional costs incurred.
2. Contractual Adjustments: Hospitals often have contracts with payers that outline adjustments based on specific cases or exceptional circumstances. The difference could be adjusted according to the terms of such agreements.
3. Uncompensated Care: If the additional costs are considered uncompensated care, the hospital may need to absorb those costs, resulting in a financial loss for the institution.
It's important to note that the resolution process might involve discussions between the hospital, payer, and possibly the patient, to determine the appropriate and fair outcome given the situation.
I hope this explanation helps you understand how the difference between the charges and the DRG reimbursement can be resolved in this scenario.