Outlier Payments

10.8 - Outlier Payments (Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20) When cases experience an unusually high level of services in a 30-day period, Medicare systems will provide additional or "outlier" payments to the case-mix and wage-adjusted 30-day period payment. Outlier payments can result from medically necessary high utilization in any or all-home health service disciplines. CMS makes outlier payments when the cost of care exceeds a threshold dollar amount. The outlier threshold for each case-mix group is the 30-day period payment amount for that group or the partial payment adjustment amount for the 30-day period, plus a fixed dollar loss amount, which is the same for all case-mix groups. The outlier payment is a proportion of the amount of imputed costs beyond the threshold. CMS calculates the imputed cost for each 30-day period by first taking the national per-visit payment amounts for each discipline and calculating per-unit payment amounts (1 unit = 15 minutes). The per-unit amounts are then multiplied by the number of units in the discipline and computing the total imputed cost for all disciplines (summed across the six disciplines of care). If the imputed cost for the 30-day period is greater than the sum of the case-mix and wage-adjusted 30-day period payment plus the fixed dollar loss amount (the outlier threshold), a set percentage (the loss sharing ratio) of the difference between the imputed amount and outlier threshold will be paid to the HHA as a wage-adjusted outlier payment in addition to the 30-day period payment. The amount of the outlier payment is determined as follows: 1. Calculate the case-mix and wage-adjusted 30-day period payment (including non- routine supplies (NRS)); 2. Add the wage-adjusted fixed dollar loss amount. The sum of steps 1 and 2 is the outlier threshold for the 30-day period; 3. Calculate the wage-adjusted imputed cost of the 30-day period by first multiplying the total number of units for each home health discipline by the national per unit amounts, and wage-adjusting those amounts. Sum the per discipline wage-adjusted imputed amounts to yield the total wage-adjusted imputed cost for the 30-day period; 4. Subtract the total imputed cost for the 30-day period (total from Step 3) from the sum of the case-mix and wage-adjusted 30-day period payment and the wage- adjusted fixed dollar loss amount (sum of Steps 1 and 2 - outlier threshold); 5. Multiply the difference by the loss sharing ratio; and 6. That total amount is the outlier payment for the 30-day period. Effective January 1, 2010, an outlier cap precludes any HHA from receiving more than 10 percent of their total home health payment in outliers.