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.
my thoughts on this was that it was basically a wright off by the hospital....but im not sure!! as i said before im kinda lost on this question!!
Hopefully the patient has a Supplemental Insurance Plan?
Sra
To understand how the difference between the charges and the DRG reimbursement gets resolved in this scenario, we need to understand the process of Medicare Part A reimbursement and the concept of Diagnosis-Related Groups (DRGs).
Medicare Part A is a federal health insurance program in the United States that provides coverage for hospital stays, skilled nursing care, and certain home health services. When a patient is admitted to a hospital, the hospital submits a claim to Medicare for reimbursement of the services provided.
The reimbursement under Medicare Part A is determined through a system called Diagnosis-Related Groups (DRGs). DRGs categorize patients into groups based on their diagnoses, treatment procedures, age, and other factors. Each DRG has a predetermined reimbursement rate, which represents the average cost of treating patients in that specific group.
In this case, you've coded a Medicare Part A record with a DRG reimbursement of $12,000. This means that based on the assigned DRG, the hospital will receive $12,000 as reimbursement for the services provided to the patient.
However, you notice that the patient's charges in the hospital's computer billing system amount to $19,500. This indicates that the hospital has charged the patient more than what they will be reimbursed under the DRG system. The $7,500 difference between the charges and the DRG reimbursement needs to be addressed.
To resolve this difference, the hospital may take various actions:
1. Adjust the charges: The hospital can review the charges and potentially adjust them to align with the DRG reimbursement. This adjustment can involve reducing certain charges or providing justification for any additional charges incurred.
2. Negotiate with Medicare: The hospital can engage in negotiations with Medicare to discuss the discrepancy between the charges and the DRG reimbursement rate. This could involve providing documentation and evidence to support higher charges or challenging the reimbursement rate for that specific DRG.
3. Write off the difference: In some cases, the hospital may choose to write off the difference between the charges and the DRG reimbursement as a financial loss. This means they accept the lower reimbursement rate and do not pursue the remaining amount from the patient.
It's important to note that the specific resolution may vary from hospital to hospital, depending on their internal policies, negotiations with Medicare, and other factors. Hospital billing departments and financial teams are responsible for managing these discrepancies and working towards a resolution.
If you have further questions or need clarification, feel free to ask.