471 NAC 46-003. PAYMENT FOR PEER GROUPS 1 METRO, 2 URBAN AND REGIONAL RURAL REFERRAL, 3 RURAL, AND 10 CHILDREN’S

003. PAYMENT FOR PEER GROUPS 1 METRO, 2 URBAN AND REGIONAL RURAL REFERRAL, 3 RURAL, AND 10 CHILDREN’S. Payments for inpatient acute care services are made on a prospective per discharge basis. For inpatient services that are classified into a diagnosis-related group, the total per discharge payment is the sum of the operating cost payment amount; the capital-related cost payment; and when applicable direct medical education (DME) cost payment; indirect medical education (IME) cost payment; and a cost outlier payment. For inpatient services that are classified into a transplant diagnosis-related group, the total per discharge payment is the sum of the transplant cost-to-charge ratio (CCR) payment amount; and when applicable transplant direct medical education (DME) cost payment. 003.01 DETERMINATION OF OPERATING COST PAYMENT AMOUNT. The hospital operating cost payment amount for discharges are classified into a diagnosis-related group and is calculated by multiplying the Peer Group base payment amount by the applicable 3M All-Patient Refined Diagnosis-Related Group grouper (APR DRG) National Weight. 003.01(A) CALCULATION OF THE ALL-PATIENT REFINED DIAGNOSIS-RELATED GROUP GROUPER (APR DRG) WEIGHTS. Hospitals are expected to submit claims in compliance with All-Patient Refined Diagnosis-Related Groups grouper (APR DRG) standards. . . 003.01(B) CALCULATION OF NEBRASKA PEER GROUP BASE PAYMENT AMOUNTS. Peer Group base payment amounts are used to calculate payments for discharges for non-transplant diagnosis-related group. Peer Group base payment amounts are subject to annual adjustment as specified by Nebraska Legislative appropriations. 003.02 CALCULATION OF DIAGNOSIS-RELATED GROUP COST OUTLIER PAYMENT AMOUNTS. Additional payment is made for approved discharges classified into a diagnosis-related group meeting or exceeding Nebraska Medicaid criteria for cost outliers for each diagnosis-related group classification. Cost outliers may be subject to medical review. Discharges qualify as cost outliers when the costs of the service exceed the outlier threshold. The outlier threshold is the sum of the operating cost payment amount, the indirect medical education (IME) cost payment , and the capital-related cost payment , plus $30,000 for all neonate and nervous system All-Patient Refined Diagnosis-Related Groups grouper (APR DRG) at severity level 3 and at severity level 4. For all other All-Patient Refined Diagnosis-Related Groups grouper (APR DRG) , the outlier threshold is the sum of the operating cost payment amount, the indirect medical education (IME) cost payment , and the capital-related cost payment plus $51,800. Cost of the discharge is calculated by multiplying the Nebraska Medicaid allowed charges by the sum of the hospital-specific Medicare operating and capital outlier cost-to-charge ratios. Additional payment for cost outliers is 80% of the difference between the hospital’s cost for the discharge and the outlier threshold for all discharges except for burn discharges, which will be paid at 85% of the difference between the hospital’s cost for the discharge and the outlier threshold. 003.02(A) HOSPITAL-SPECIFIC MEDICARE OUTLIER COST-TO-CHARGE RATIOS (CCR). Hospitals excluded from the Medicare prospective payment system under federal regulations will have a provider-specific cost-to-charge ratio (CCR) calculated using all-payer data from their Medicare cost report. An out-of-state hospital’s outlier cost-to-charge ratio (CCR) is the average of in-state hospitals within the same Peer Group. The cost-to-charge ratio (CCR) outlier is not subject to Nebraska Legislative appropriations. 003.03 CALCULATION OF DIRECT MEDICAL EDUCATION (DME) COSTS. 003.03(A) CALCULATION OF DIRECT MEDICAL EDUCATION (DME) COST PAYMENTS. Direct medical education (DME) cost payments shall be made to eligible Nebraska teaching hospitals and are based on hospital-specific direct medical education (DME) cost payment rates determined each state fiscal year. The direct medical education (DME) cost payment amounts are subject to annual adjustment as specified by Nebraska Legislative appropriations. 003.03(B) CALCULATION OF INDIRECT MEDICAL EDUCATION (IME) COST PAYMENTS. . Indirect medical education (IME) cost payments shall be made to eligible Nebraska teaching hospitals and are calculated by multiplying an indirect medial education (IME) factor by the operating cost payment amount. Hospitals excluded from the Medicare prospective payment system under federal regulations will have a provider specific intern-to-bed ratio calculated using their Medicare cost report. The intern-to-bed ratio is then utilized in the following formula to calculate the annual indirect medical education (IME) factor: number of interns and residents divided by available beds; plus 1; to the power of 0.405; minus 1; multiplied by 1.35. The indirect medical education (IME) factor is not subject to Nebraska Legislative appropriations. 003.03(C) CALCULATION OF CAPITAL-RELATED COST PAYMENT. Capital-related cost payments for the building and fixtures portion of capital-related costs are paid on a per discharge basis. Per discharge amounts are calculated by multiplying the capital per diem cost by the statewide average length-of-stay for the diagnosis-related group. Capital-related payment per diem amounts are calculated for Peer Groups 1 Metro Acute Care Hospitals, 2 Urban Acute Care and Regional Rural Referral Hospitals, 3 Rural Acute Care Hospitals and 10 Children’s Hospitals. , The Peer Group specific capital-related payment per diem amounts shall be adjusted by the available funds appropriated by the Nebraska Legislature. 003.03(D) TRANSPLANT DIAGNOSIS-RELATED GROUP PAYMENTS. Transplant discharges, identified as discharges that are classified to a transplant diagnosis-related group, are paid a transplant diagnosis-related group cost-to-charge ratio (CCR) payment and, if applicable, a direct medical education (DME) payment. Transplant diagnosis-related group discharges do not receive separate cost outlier payments, indirect medical education (IME) cost payments or capital-related cost payments. 003.03(D)(i) TRANSPLANT DIAGNOSIS-RELATED GROUP COST-TO-CHARGE RATIO (CCR) PAYMENTS. Transplant diagnosis-related group cost-to-charge ratio (CCR) payments are calculated by multiplying the hospital-specific transplant diagnosis-related group cost-to-charge ratio (CCR) by Nebraka Medicaid-allowed claim charges. On July 1 of each year, Nebraska Medicaid will update the transplant diagnosis-related group cost-to-charge ratios (CCR) using the following method: divide the previous year outlier cost-to-charge ratio (CCR) by the current year outlier cost-to-charge ratio (CCR) to determine the percentage of change; then multiply this by the percentage of change by the previous state fiscal year transplant cost-to-charge ratio (CCR); then multiply the product by any applicable state legislative appropriations. Out-of-state hospital transplant cost-to-charge ratio (CCR) is the average of in-state hospitals within the same Peer Group. 003.03(D)(ii) TRANSPLANT DIAGNOSIS-RELATED GROUP DIRECT MEDICAL EDUCATION (DME) PAYMENTS. Transplant diagnosis-related group direct medical education (DME) cost payments are based on Nebraska hospital-specific direct medical education (DME) payment rates determined each state fiscal year. Bone marrow transplant diagnosis-related groups are excluded from transplant direct medical education (DME) rate and are reimbursed under the specific hospital direct medical education (DME) rate. Each state fiscal year Nebraska hospital-specific transplant direct medical education (DME) payment rates shall be adjusted by a percentage. This percentage shall be determined by Nebraska Legislature appropriations. The transplant direct medical education (DME) payment rates are adjusted annually and shall be effective each July 1. . 003.03(E) BUDGET NEUTRALITY FACTORS. Peer Group base payment amounts, are multiplied by budget neutrality factors in the process of setting payment rates. 003.03(E)(i) DEVELOP FISCAL SIMULATION ANALYSIS. Nebraska Medicaid will develop a fiscal simulation analysis using Nebraska Medicaid inpatient paid claims data . The fiscal simulation analysis includes discharges grouped into a diagnosis-related group and excludes all psychiatric, rehabilitation, and transplant discharges. In the fiscal simulation analysis, Nebraska Medicaid will apply all rate year payment rates before budget neutrality adjustments to the claims data and simulate payments. 003.03(E)(ii) DETERMINE BUDGET NEUTRALITY FACTORS. Nebraska Medicaid will set budget neutrality factors in fiscal simulation analysis such that simulated payments are equal to the claims data reported payments, inflated by Peer Group base payment amount increases approved by Nebraska Medicaid from the end of the claims data period to the rate year. 003.03(F) FACILITY SPECIFIC UPPER PAYMENT LIMIT. Facilities in Peer Groups 1, 2, 3, and 10 are subject to an upper payment limit for all cost reporting periods . For each cost reporting period, Nebraska Medicaid payment for inpatient hospital services shall not exceed 110% of Nebraska Medicaid cost. Nebraska Medicaid cost shall be the calculated sum of Nebraska Medicaid allowable inpatient routine and ancillary service costs. Nebraska Medicaid routine service costs are calculated by allocating total hospital routine service costs for each applicable routine service cost center. Nebraska Medicaid inpatient ancillary service costs are calculated by multiplying an overall ancillary cost-to-charge ratio (CCR) times the applicable Nebraska Medicaid program inpatient ancillary charges. The overall ancillary cost-to-charge ratio (CCR) is calculated by dividing the sum of the costs of all ancillary and outpatient service cost centers by the sum of the charges for all ancillary and outpatient service cost centers. Payments shall include all operating cost payments, capital related cost payments, direct medical education (DME) cost payments, indirect medical education (IME) cost payments, cost outlier payments, and all payments received from other sources for hospital care provided to Nebraska Medicaid eligible beneficiaries. Payment under Nebraska Medicaid shall constitute reimbursements under this subsection for days of service that occurred during the cost reporting period. 003.03(F)(i) RECONCILIATION TO FACILITY UPPER PAYMENT LIMIT. Facilities will be subject to a preliminary and a final reconciliation of Nebraska Medicaid payments to allowable Nebraska Medicaid costs. A reconciliation will be made within six months following receipt by Nebraska Medicaid of the facilities settled cost report. Facilities will have 60 days to make refunds to Nebraska Medicaid, when notified that an overpayment has occurred. Facilities will be notified when either the preliminary or final reconciliation indicates that the facility received Nebraska Medicaid payments more than 110% of Nebraska Medicaid costs. Nebraska Medicaid will identify the cost reporting period for Nebraska Medicaid payments, Nebraska Medicaid costs, and the amount of overpayment that is due to Nebraska Medicaid. 003.03(G) TRANSFERS. When a beneficiary is transferred to or from another hospital, Nebraska Medicaid shall make a transfer payment to the transferring hospital if the initial admission is determined to be medically necessary. For hospital inpatient services reimbursed on a prospective discharge basis, the transfer payment is calculated based on the average daily rate of the transferring hospital's payment for each day the beneficiary remains in that hospital, up to 100 % of the full diagnosis-related group payment. The average daily rate is calculated as the full diagnosis-related group payment, which is the sum of the operating cost payment amount, capital-related cost payment, and if applicable, direct medical education (DME) cost payment, divided by the statewide average length-of-stay for the related diagnosis-related group. For hospitals receiving a transferred beneficiary, payment is the full diagnosis-related group payment and, if applicable, cost outlier payment. 003.03(H) INPATIENT ADMISSION AFTER OUTPATIENT SERVICES. A beneficiary may be admitted to the hospital as an inpatient after receiving hospital outpatient services. When a beneficiary is admitted as an inpatient within three calendar days of the day that the hospital outpatient services were provided, all hospital outpatient services related to the principal diagnosis are considered inpatient services for billing and payment purposes. The day of the admission as an inpatient is the first day of the inpatient hospitalization. 003.03(I) READMISSIONS. Nebraska Medicaid adopts Medicare peer review organization regulations to control increased admissions or reduced services. All Nebraska Medicaid beneficiaries readmitted as an inpatient within 31 days will be reviewed by Nebraska Medicaid or its designee. Payment may be denied if either admissions or discharges are performed without medical justification as determined medical review. 003.03(J) INTERIM PAYMENT FOR LONG-STAY BENEFICIARIES. Nebraska Medicaid’s payment for hospital inpatient services is made upon the beneficiary’s discharge from the hospital. Occasionally, a beneficiary may have an extremely long stay, in which partial reimbursement to the hospital may be necessary. A hospital may request an interim payment if the beneficiary has been hospitalized 60 days and is expected to remain hospitalized an additional 60 days. To request an interim payment, the hospital shall send the appropriate completed Nebraska Medicaid approved health care claim form , for the hospital days for which the interim payment is being requested with an attestation by the attending physician that the beneficiary has been hospitalized a minimum of 60 days and is expected to remain hospitalized a minimum of an additional 60 days. 003.03(J)(i) FINAL PAYMENT FOR LONG-STAY BENEFICIARIES. When an interim payment is made for long-stay beneficiaries, the hospital shall submit a final billing for payment upon discharge of the beneficiary. The date of admission for the final billing must be the date the beneficiary was admitted to the hospital as an inpatient. The statement from and to dates must be the date the beneficiary was admitted to the hospital through the date the beneficiary was discharged. The total charges must be all charges incurred during the hospitalization. Payment for the entire hospitalization will be calculated at the same rate as all prospective discharge payments. The final payment will be reduced by the amount of the interim payment. 003.03(K) PAYMENT FOR CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) FEES. A certified registered nurse anesthetist (CRNA) provider may choose to retain their billing privileges and submit claims directly for certified registered nurse anesthetist (CRNA) charges, which would follow the anesthesia fee schedule. The critical access hospital (CAH) or rural emergency hospital may also elect one of the following two options to bill for certified registered nurse anesthetist (CRNA) professional fees on behalf of the certified registered nurse anesthetist (CRNA) provider. Certified registered nurse anesthetist (CRNA) providers in either circumstance must reassign billing privileges to the critical access hospital (CAH) or rural emergency hospital. In cases when Medicare is the primary payer, the provider must follow Medicare billing requirements. In either option below, the certified registered nurse anesthetist (CRNA) provider must not separately bill for charges that occurred in the critical access hospital (CAH) or rural emergency hospital for which they have reassigned billing privileges: (i) A critical access hospital (CAH) may choose to bill on a professional claim form for both inpatient and outpatient certified registered nurse anesthetist (CRNA) services. A rural emergency hospital may choose to bill on a professional claim form for outpatient certified registered nurse anesthetist (CRNA) services. Reimbursement will follow the Nebraska Medicaid anesthesia fee schedule; or (ii) The critical access hospital (CAH) may bill on an institutional claim form for both inpatient and outpatient professional certified registered nurse anesthetist (CRNA) costs using revenue code 964 for certified registered nurse anesthetist (CRNA) professional fees. Reimbursement will be based on critical access hospital (CAH) inpatient or outpatient applicable rates and are subject to cost settlement. A rural emergency hospital may bill on an institutional claim form for outpatient professional certified registered nurse anesthetist (CRNA) costs using revenue code 964 for certified registered nurse anesthetist (CRNA) professional fees. Reimbursement for rural emergency hospitals will be based on outpatient applicable rates.