90-351 C.M.R. ch. 5, § 3 - INPATIENT FACILITY FEES

3.01 BILLING

Bills for inpatient services must be submitted on a CMS Uniform Billing (UB-04) form. Health care providers are not required to provide the MS-DRG. Inpatient bills without the MS-DRG do not constitute uncoded bills.

3.02 ACUTE CARE HOSPITALS

The base rate for inpatient services at acute care hospitals is $11,121.68.

3.03 CRITICAL ACCESS HOSPITALS

The base rate for inpatient services at critical access hospitals is $11,788.98.

3.04 [Reserved]

3.05 PAYMENT CALCULATION

Pursuant to 39-A M.R.S.A. §209-A, the medical fee schedule for services rendered by health care facilities must reflect the methodology and categories set forth in the federal Centers for Medicare and Medicaid Services severity-diagnosis related group system for inpatient services. Inpatient fees are calculated by multiplying the base rate times the MS-DRG weight. In the event of a dispute regarding the fee listed in Appendix III, the listed relative weight times the base rate controls. For inpatient services that take place during two different calendar years, payment is calculated based on the fees in effect on the discharge date.

3.06 OUTLIER PAYMENTS

The threshold for outlier payments is $75,000.00 plus the fee established in Appendix III. If the outlier threshold is met, the outlier payment is the charges above the threshold multiplied by 75%.

3.07 IMPLANTABLES

Where an implantable exceeds $10,000.00 in cost, an acute care or critical access hospital may seek additional reimbursement by submitting a copy of the invoice(s) along with the bill. Invoices need not be requested by the employer/insurer. Reimbursement is set at the actual amount paid plus $500.00. Handling and freight charges must be included in the hospital's invoiced cost and are not to be reimbursed separately. When a hospital seeks additional reimbursement for an implantable, the implantable charge is excluded from any payment calculation.

3.08 SERVICES INCLUDED

All services provided during an uninterrupted patient encounter leading to an inpatient admission must be included in the inpatient stay. Services do not include costs related to transportation of a patient to obtain medical care. Costs related to transportation are payable separately.

3.09 FACILITY TRANSFERS

The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two hospitals:

1. A hospital transferring a patient is paid as follows: The MS-DRG reimbursement amount is divided by the number of days duration listed for the DRG; the resultant per diem amount is then multiplied by two for the first day of stay at the transferring hospital; the per diem amount is multiplied by one for each subsequent day of stay at the transferring hospital; and the amounts for each day of stay at the transferring hospital are totaled. If the result is greater than the MS-DRG reimbursement amount, the transferring hospital is paid the MS-DRG reimbursement amount. Associated outliers and add-ons are then added to the payment.

2. A hospital discharging a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons.

3. Facility transfers do not include costs related to transportation of a patient to obtain medical care. Costs related to transportation are payable separately.

3.10 OTHER INPATIENT FACILITY FEES

Inpatient services provided by institutional health care providers other than acute care or critical access hospitals must be paid at 75% of the provider's usual and customary charge.

3.11 PROFESSIONAL SERVICES

Individual health care providers who furnish professional services in an inpatient setting must be reimbursed using the fees set forth in Appendix II. The individual health care provider's charges are excluded from any calculation of inpatient facility fees.

Notes

90-351 C.M.R. ch. 5, § 3