HSCRC Rate System
Arin Foreman
Senior Associate - KPMG LLP
arinforeman@kpmg.com
Jennifer Hulvey
Director of Reimbursement - Frederick Memorial Hospital
jhulvey@fmh.org
January 31, 2014
Discussion Topics
•
•
•
•
•
•
•
•
Overview – Revenue Methodologies
Rate Order
Annual Rate Order Adjustments
Unit Rate Compliance
Total Revenue Compliance
Reasonableness of Charges
Required Reporting
Terminology and Acronyms
Overview
• HSCRC has developed methodologies to constrain
healthcare costs in Maryland.
• Hospitals currently elect one of the following:
– Total Patient Revenue (TPR) System,
– Charge per Case (CPC) System, or
– Charge per Episode / Admission-Readmission Revenue
(CPE / ARR)
Total Patient Revenue (TPR)
• Inpatient and outpatient revenue is constrained by the TPR
System
• Implemented July 1, 2010 (Garrett County Memorial
Hospital and Edward W. McCready Memorial Hospital
transitioned to TPR prior to 07/01/10)
• Approved revenue amount in a given year is a fixed cap
• No adjustment for changes in volume
• No adjustment for changes in Case Mix Index (CMI)
• Available to sole community provider hospitals and hospitals
operating in regions of the State that don’t share service
areas with other hospitals
Charge per Case (CPC)
• Inpatient Revenue is constrained by the Charge per Case
system (CPC)
• Fixed amount of revenue per inpatient case
• Implemented July 1, 2005
• Each hospital's allowed CPC is based on their Case Mix
Index (CMI)
• CMI measures the complexity of a hospital's cases
Charge per Episode (CPE)
• Admission-Readmission Revenue arrangement (ARR):
– Fixed amount of revenue per inpatient episode
– Under ARR, hospitals assume the risks and rewards of
managing hospital readmissions.
– No revenue increase for additional readmissions (penalty)
– No revenue decrease for reduced readmissions (reward)
• Implemented July 1, 2011
• Voluntary 3-year revenue constraint program replacing CPC
• Excludes intra-hospital readmissions within 30 days
• All cause readmissions
• Each hospital's allowed CPE is based on Case Mix Index
(CMI)
Which rate methodology is your hospital under?
TPR
Calvert Memorial Hospital
Carroll Hospital Center
Chester River Hospital Center
Dorchester General Hospital
Edward W. McCready Hospital
Garrett County Memorial Hospital
Memorial Hospital at Easton
Meritus Medical Center
Union Hospital of Cecil County
Western MD Regional Medical Center
CPC
Atlantic General Hospital
Fort Washington Medical Center
Laurel Regional Hospital
Prince Georges Hospital Center
Southern Maryland Hospital Center
CPE / ARR
Anne Arundel Medical Center
Baltimore Washington Medical Center
Bon Secours Hospital
Civista Medical Center
Doctors Community Hospital
Franklin Square Hospital Center
Frederick Memorial Hospital
Good Samaritan Hospital
Greater Baltimore Medical Center
Harbor Hospital Center
Harford Memorial Hospital
Holy Cross Hospital
Howard County General Hospital
Johns Hopkins Bayview Medical Center
Johns Hopkins Hospital
Kernan Hospital
Maryland General Hospital
Mercy Medical Center
Montgomery General Hospital
Northwest Hospital Center
Peninsula Regional Medical Center
Shady Grove Adventist Hospital
Sinai Hospital
St. Agnes Hospital
St. Joseph Medical Center
St. Mary's Hospital
Suburban Hospital
Union Memorial Hospital
University of Maryland Medical Center
Upper Chesapeake Medical Center
Washington Adventist Hospital
RATE ORDER
HEALTH SERVICES COST REVIEW COMMISSION
NEW APPROVED CHARGE PER EPISODE TARGETS AND RATES
for
Frederick Memorial Hospital
Effective:
July 1, 2013
FINAL
Charge per Episode (CPE) Target & Casemix Indexes
Permanent CPE $10,543
Compliance CPE $10,607
Base CPE Casemix Index 1.011528
Revenue Center
Med./Surg. Acute
Pediatrics
Admissions
Emergency Services
Clinic Services
Psychiatric Day/Night
Operating Room
Same Day Surgery
Labor and Delivery
Laboratory
Nuclear Medicine
Renal Dialysis
Leukapheresis
TUMT
MRI Scanner
Hyperbaric Chamber
(R)
Service
Unit
Unit
Rates
Patient Days
Patient Days
Admission
MD RVU'S
RVU'S
Visits
Minutes
Per Patient
RVU'S
MD RVU'S
HSCRC RVU'S
Treatments
JHH RVU'S
Procedure
RVU'S
Hrs of Treatment
$ 854.1740
$ 1,033.6924
$ 151.7719
$
37.6217
$
22.2031
$ 252.9133
$
25.2681
$ 632.1710
$ 107.7558
$
1.8902
$
23.7300
$ 777.9715
$ 1,640.1178
$ 6,855.5597
$ 103.9810
$ 316.6025
(R) = Rebundled Service
CHARGES for MEDICAL SUPPLIES and DRUGS SOLD
Budgeted
Annual
Revenue
Budgeted
Volume
60,972 $
805
18,967
636,025
333,241
2,417
1,065,699
8,641
87,994
15,824,464
75,401
1,184
1
1
87,038
1,607
52,080,697
832,122
2,878,658
23,928,342
7,398,983
611,291
26,928,189
5,462,590
9,481,864
29,911,402
1,789,266
921,118
1,640
6,856
9,050,298
508,780
$
255,255,646
TOTAL
Maximum
Annual
Overhead
Mark up
Med./Surg. Supplies
Drugs
Invoice Cost plus
Invoice Cost plus
1.1206 , plus Overhead.
1.1206 , plus Overhead.
$
$
12,025,772
14,813,263
Rate Order
• Revenue Center: Hospitals
have different revenue centers
depending on the services they
provide
• Service Unit: The service unit is
the same for all hospitals (i.e.
every hospital charges for
Operating Room services by
the minute)
• Unit Rates: Unit rates (prices)
vary by hospital
– These rates must be
charged to all payers - no
contract negotiations
Revenue Center
Service
Unit
Med./Surg. Acute
New Born Nursery
Admissions
Psychiatric Day/Night
Operating Room
Radiology-Diagnostic
Renal Dialysis
Patient Days
Patient Days
Admission
Visits
Minutes
RVU'S
Treatments
Unit
Rates
$
$
$
$
$
$
$
854.1740
518.2096
151.7719
252.9133
25.2681
26.4154
777.9715
RVUs
• RVUs relate to the
complexity (time and cost) of
tests and procedures
• The service units for RVU's
(relative value units) are
defined by the HSCRC in
Appendix D
• For example, a chest x-ray,
single view, has the same
RVU at all MD hospitals
APPENDIX D
STANDARD UNIT OF MEASURE REFERENCES
DIAGNOSTIC RADIOLOGY
CPT
CODE
71010
71015
71023
71030
DESCRIPTION
Chest, single view, posteroanterior
Stereo, frontal
With fluoroscopy
Chest, complete, minimum of 4 views
RVU's
2
3
6
5
The patient charge becomes a calculation…
Revenue Center
Service
Unit
Med./Surg. Acute
New Born Nursery
Admissions
Psychiatric Day/Night
Operating Room
Radiology-Diagnostic
Renal Dialysis
Patient Days
Patient Days
Admission
Visits
Minutes
RVU'S
Treatments
CPT
CODE
71010
71015
71023
71030
DESCRIPTION
Chest, single view, posteroanterior
Stereo, frontal
With fluoroscopy
Chest, complete, minimum of 4 views
Unit
Rates
$
$
$
$
$
$
$
854.1740
518.2096
151.7719
252.9133
25.2681
26.4154
777.9715
RVU's
2
3
6
5
2 RVU's x $26.4154 =
$52.83
Updates to Rate Orders
• Hospitals receive an updated rate order once per year effective July 1st
• Unit rates are updated for:
Inflation (update factor)
Rate realignment
Change in approved mark-up (UCC)
Volume adjustment
Other one time adjustments (quality, assessments)
Compliance
Population
Change in case mix (CMI)
CPC/CPE
x
x
x
x
x
x
x
TPR
x
x
x
x
x
x
History of Update Factors
• The following chart displays the previous five years’
update/inflation factors that have been applied to hospitals’
rates:
FY 2014 FY 2013 FY 2012 FY 2011 FY 2010
Inpatient
1.65%
-1.00%
2.20%
1.68%
1.77%
Outpatient
1.65%
2.59%
3.05%
2.53%
1.27%
Rate Realignment
• Charges are related to the underlying cost of providing the
service
• This does not change a hospital's total revenue; it just
reallocates it among revenue centers
• Costs for FY 2012 were used to realign FY 2014 rates
Rate Realignment
Cases
1.
Base Period CPC Compliance Target
14,957 X
2.
Reversal of Previous One-Time Adjustments
CPC Retros
3.
Net Current Base Period Cases & Revenue (1)
4.
Change in Casemix Index
Base period Casemix Index (CMI)
Permanent Period CMI
Total Casemix Change
Other
Net Casemix Change
Net Allowable Casemix Revenue FYE
5.
6.
7
8
Approved
Revenue
CPC Target
10,000
=
-293
15,299 X
9,707
15,299
9,539
149,573,461
-4,386,253
=
148,506,993
0.861135
0.846192
-1.735%
0.000%
-1.735%
Jun-11
145,929,989
Trims and Exclusions
FYE
Jun-11
Other
Other
Other
Adjusted Permanent CPC Target & Revenue
0
0
0
145,929,989
Other Permanent CPC Target & Revenue Adjustments
Other Permanent
Permanent CPC Revenue to be Rate Realigned
0
145,929,989
Rate Realignment
Using the M schedule from the most recent Annual Filing, the Revenue
calculated in the previous step is realigned based on the Volume adjusted cost
in each center. For example, if MSG has 15% of the costs, then 15% of the
revenue will be allocated to that center.
MSG
PED
PSY
OBS
DEF
MIS
NUR
EMG
CL
ADM
SDS
DEL
OR
ANS
LAB
EKG
RAD
CAT
RAT
NUC
RES
Med./Surg. Acute
Pediatrics
Psychiatric Acute
Obstetric Acute
Definitive Observation
Med./Surg. I.C.U.
New Born Nursery
Emergency Services
Clinic Services
Admissions
Same Day Surgery
Labor and Delivery
Operating Room
Anesthesiology
Laboratory
Electrocardiography
Radiology-Diagnostic
CT Scanner
Radiology-Therapeutic
Nuclear Medicine
Respiratory Therapy
Units per
Schedule M
Revenue per
Schedule M
44,794
1,236
4,830
4,850
7,173
5,744
5,373
673,807
242,609
16,270
9,704
63,147
1,112,319
777,116
10,704,414
422,366
281,506
641,186
7,420
85,424
2,984,919
31,840
1,094
3,224
3,570
6,689
9,156
3,396
17,037
4,807
1,472
2,371
2,806
17,482
1,880
16,894
1,063
6,603
2,708
260
1,778
4,248
Actual
Inpatient
Units
44,882
1,403
4,297
4,723
6,841
5,598
5,107
164,586
74
16,482
0
53,033
476,188
431,124
7,387,753
246,449
135,456
274,526
5,286
24,513
2,601,939
Actual
Outpatient
Units
0
0
0
0
0
0
0
524,236
252,246
0
9,810
10,576
824,950
347,512
3,616,255
202,721
158,983
386,008
1,160
56,364
325,142
Actual
Total
Units
44,882
1,403
4,297
4,723
6,841
5,598
5,107
688,822
252,320
16,482
9,810
63,609
1,301,138
778,636
11,004,008
449,170
294,439
660,534
6,446
80,877
2,927,081
Variable
Cost
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
1.0000
% Change
In Units
0.2%
13.5%
-11.0%
-2.6%
-4.6%
-2.5%
-5.0%
2.2%
4.0%
1.3%
1.1%
0.7%
17.0%
0.2%
2.8%
6.3%
4.6%
3.0%
-13.1%
-5.3%
-1.9%
Volume Adjusted Revenue Excluded
Schedule M
From
Revenue
Rate Realignment
31,902
1,242
2,868
3,476
6,379
8,923
3,228
17,417
4,999
1,491
2,397
2,827
20,449
1,884
17,367
1,131
6,906
0
226
1,684
4,165
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3,594,307
0
0
0
Prorated
Current
Revenue
36,959,127
1,438,919
3,322,357
4,027,360
7,390,611
10,337,830
3,739,641
20,177,627
5,791,635
1,727,784
2,777,070
3,274,917
23,690,437
2,182,610
20,120,028
1,310,143
8,000,851
3,594,307
261,271
1,950,521
4,825,656
UCC
• Uncompensated Care includes charity care and bad debt
• The UCC policy allows hospitals to charge additional
amounts in their rates to all payors to cover the shortfall
produced by providing uncompensated care
• Blend of:
– Three-year average
– Predicted UCC
UCC
• Three-year average is based on the Hospital’s 3 most
recent year’s Annual Filings
• Predicted UCC uses a linear regression model
– Independent variable (x): Actual Uncompensated Care
– Dependent variables (y):
• Inpatient Medicaid, Self Pay, and Charity Charges as a % of
Total Charges
• Inpatient Charges from non-Medicare Admissions through the ER
as a % of Total Charges
• Outpatient Medicaid, Self Pay, and Charity Charges from the ER
as a % of Total Charges
• Outpatient Charges from non-Medicare ER Visits as a % of Total
Charges
UCC
• UCC Pool – since Statewide UCC % is built into all
hospitals’ rates, the UCC Pool acts as a settlement
methodology to account for hospitals that experience more
or less UCC than the State
Hospital A
Hospital B
Hospital C
UCC Policy
Result
15.00%
7.47%
3.50%
Statew ide
UCC %
7.47%
7.47%
7.47%
UCC Above /
(Below ) Average
7.53%
0.00%
-3.97%
Volume Adjustment
• Rates are adjusted for volume increases and decreases
• FY 2014 rates adjusted for volume changes occurring in FY 2013
• Variable Cost Factor = 85% / Fixed = 15%
– Volume increases - 15% of volume increase taken out of rates
– Volume decreases - 15% is put into rates
• Changes Effective Jan 1, 2014
– Adjustment will be made on a concurrent basis (during the
year in which the volume change occurs)
– Variable Cost Factor = 50% / Fixed = 50%
Volume Adjustment
Total
Clinic
Volumes
706
32,345
Base Year:
Inpatient
16,529
Other
15,109
Rate Year:
16,281
14,855
706
31,843
Change
248
254
0
502
Allowable (x 85%)
211
216
0
427
Volume Adj
-0.23%
Assessments
• Two assessments pass through hospitals in order to support
“medically uninsurable” patients and Medicaid expansion
– MHIP (Maryland Health Insurance Plan)
– Health Care Coverage Fund
• Medicaid Budget Deficit Assessment
– State total spread to hospitals based on % of total
revenue
– Payer portion put into rates (all-payers)
86%
– Hospital portion paid by hospital throughout year 14%
• NSP I (Nursing Support Program) – grant funding
– Applied directly to admissions center
Application of Assessments
Revenue after
application of
Current Year Price
Variances and
Penalties
Center
MSG
MIS
ADM
EMG
OR
ANS
SDS
LAB
EKG
EEG
RAD
RAT
NUC
CAT
IRC
RES
Revenue
After
Rate
Allocation
Realignment
%
$55,482,772
0.2654
14,115,942
0.0675
1,285,404
0.0061
21,129,159
0.1011
20,814,461
0.0996
839,189
0.0040
3,572,228
0.0171
15,617,999
0.0747
1,793,363
0.0086
4,754,200
0.0227
9,528,006
0.0456
479,995
0.0023
1,105,079
0.0053
2,516,377
0.0120
1,595,443
0.0076
2,463,807
0.0118
Applied based on % of Revenue in that
center
MHIP
Adjustment
$1,905,069
Final
$505,662
128,651
11,715
192,568
189,700
7,648
32,557
142,340
16,344
43,329
86,837
4,375
10,072
22,934
14,541
22,455
NSP I is
applied
directly to
the
Admissions
Center
Allocated Center Adjustments
Revenue
Health Care
Defict
Total
After
Coverage Fund Assessment
Allocated
NSP I
All
$2,742,381
$5,797,825 Adjustment = Adjustment Adjustments
$10,445,275
$727,909
$1,538,914
2,772,485
$58,255,257
185,195
391,531
705,376
14,821,318
16,864
35,653
64,232
218,580
1,568,216
277,205
586,055
1,055,828
22,184,987
273,076
577,326
1,040,103
21,854,564
11,010
23,276
41,934
881,124
46,866
99,082
178,505
3,750,733
204,901
433,193
780,434
16,398,433
23,528
49,742
89,615
1,882,977
62,373
131,866
237,568
4,991,768
125,003
264,276
476,116
10,004,122
6,297
13,314
23,985
503,980
14,498
30,651
55,221
1,160,300
33,014
69,796
125,744
2,642,121
20,932
44,252
79,725
1,675,168
32,324
68,338
123,117
2,586,923
This revenue produces the Rate
Order Rates to be used in Unit
Rate Compliance
New Approved
Volume
MSG
MIS
ADM
EMG
OR
ANS
SDS
LAB
EKG
EEG
RAD
RAT
NUC
CAT
IRC
RES
50,436
6,400
13,147
618,489
899,322
765,657
7,205
10,041,667
686,384
405,224
311,206
17,019
79,507
549,763
54,954
1,619,264
Revenue
58,255,257
14,821,318
1,568,216
22,184,987
21,854,564
881,124
3,750,733
16,398,433
1,882,977
4,991,768
10,004,122
503,980
1,160,300
2,642,121
1,675,168
2,586,923
Rate
1,155.0333
2,315.8310
119.2831
35.8697
24.3012
1.1508
520.5736
1.6330
2.7433
12.3185
32.1463
29.6128
14.5937
4.8059
30.4831
1.5976
Quality Based Reimbursement
• Implemented – July 2008
• What’s Measured –
Clinical/Process
HCAPS
Outcome
Measurement Period
CY13 - going into FY15
rates
40%
50%
10%
Measurement Period
CY14 - going into FY16
rates
30%
40%
30%
• Source of Data – CMS QIO Clinical Warehouse
• Measurement Period - Calendar Year
– For example, results from CY 2013 will impact FY 2015 rates
• % of Revenue at Risk: 0.5% (increasing to 1.0% in FY 2016 rates)
• Other - Revenue Neutral - some hospitals "win" and some "lose“
– net result to the state is $0
HOSPITAL NAME
B
Southern Maryland Hospital Center
Greater Baltimore Medical Center
Prince Georges Hospital Center
Sinai Hospital
Atlantic General Hospital
Northwest Hospital Center
Peninsula Regional Medical Center
Frederick Memorial Hospital
Fort Washington Medical Center
Suburban Hospital
Calvert Memorial Hospital
Bon Secours Hospital
Harbor Hospital Center
Chester River Hospital Center
Union Memorial Hospital
Meritus Hospital
Laurel Regional Hospital
Howard County General Hospital
Franklin Square Hospital Center
Washington Adventist Hospital
St. Agnes Hospital
Johns Hopkins Bayview Medical Center
Shady Grove Adventist Hospital
Good Samaritan Hospital
Western Maryland Regional Medical Center
Garrett County Memorial Hospital
Montgomery General Hospital
Civista Medical Center
Carroll Hospital Center
Union of Cecil
Harford Memorial Hospital
Holy Cross Hospital
St. Joseph Medical Center
Doctors Community Hospital
Johns Hopkins Hospital
University of Maryland Hospital
Upper Chesapeake Medical Center
Anne Arundel Medical Center
Mercy Medical Center
Memorial Hospital at Easton
Dorchester General Hospital
Baltimore Washington Medical Center
Maryland General Hospital
St. Mary's Hospital
McCready Memorial Hospital
Statewide Total
GROSS INPATIENT
CPC/CPE REVENUE
C
$146,082,502
$208,875,651
$175,673,564
$365,095,082
$35,569,941
$125,688,476
$235,561,632
$179,085,665
$20,591,728
$146,894,874
$57,014,942
$72,763,474
$120,286,962
$34,409,502
$223,141,625
$170,280,942
$55,032,232
$148,552,102
$244,662,796
$172,399,246
$223,703,417
$254,179,825
$205,252,257
$185,067,078
$162,173,440
$18,335,488
$86,987,493
$65,004,737
$133,858,715
$64,046,952
$46,419,174
$284,622,588
$200,080,034
$121,919,094
$844,917,135
$787,107,460
$117,444,944
$241,861,191
$188,060,788
$117,317,772
$37,355,818
$188,870,979
$119,697,303
$54,639,193
$5,196,783
$7,691,782,590
QBR FINAL SCORE
D
0.4096
0.4099
0.4106
0.4338
0.4638
0.4873
0.5015
0.5338
0.5356
0.5494
0.5519
0.5848
0.5857
0.5951
0.6085
0.6102
0.6105
0.6168
0.6174
0.6174
0.6182
0.6294
0.6414
0.668
0.6787
0.6791
0.6795
0.7013
0.7114
0.7316
0.7368
0.7396
0.7441
0.7485
0.7501
0.7597
0.7786
0.7822
0.7911
0.7958
0.8005
0.83
0.8301
0.905
0.923
REVENUE
NEUTRAL
ADJUSTED
PERCENT
E
-0.50%
-0.50%
-0.50%
-0.45%
-0.39%
-0.34%
-0.31%
-0.24%
-0.24%
-0.21%
-0.21%
-0.14%
-0.14%
-0.12%
-0.09%
-0.09%
-0.09%
-0.07%
-0.07%
-0.07%
-0.07%
-0.05%
-0.02%
0.03%
0.05%
0.05%
0.05%
0.09%
0.11%
0.15%
0.16%
0.17%
0.18%
0.18%
0.19%
0.21%
0.24%
0.25%
0.27%
0.27%
0.28%
0.34%
0.34%
0.49%
0.52%
0.00%
REVENUE NEUTRAL
ADJUSTED REVENUE
IMPACT OF SCALING
F
-$730,413
-$1,043,091
-$874,760
-$1,644,016
-$138,255
-$427,868
-$733,199
-$438,613
-$49,672
-$312,708
-$118,445
-$101,996
-$166,388
-$40,954
-$204,173
-$149,860
-$48,093
-$110,601
-$179,143
-$126,231
-$160,121
-$123,467
-$49,115
$53,270
$80,092
$9,197
$44,300
$60,392
$150,391
$96,868
$74,855
$474,323
$350,770
$224,071
$1,578,877
$1,616,344
$283,917
$601,451
$499,890
$322,463
$106,058
$643,512
$408,057
$265,070
$27,012
$0
Maryland Hospital Acquired Conditions (MHAC)
• Implemented – July 2009
• What’s Measured - Potentially preventable complications (PPC's)
– Diagnosis present on admission? If no, penalized
• Source of Data - Quarterly discharge data submitted by hospitals
• Measurement Period - Calendar year
– For example, results from CY 2013 will impact FY 2015 rates
• % of Revenue at Risk: 2.0% for attainment, 1.0% for improvement
• Other - Revenue Neutral - some hospitals "win" and some "lose“
– net result to the state is $0
HOSPITAL NAME
B
Greater Baltimore Medical Center
Johns Hopkins Hospital
Union of Cecil
Harbor Hospital Center
Suburban Hospital
St. Joseph Medical Center
Chester River Hospital Center
Southern Maryland Hospital Center
University of Maryland Hospital
Sinai Hospital
Montgomery General Hospital
Garrett County Memorial Hospital
Johns Hopkins Bayview Medical Center
Calvert Memorial Hospital
Frederick Memorial Hospital
Meritus Hospital
St. Agnes Hospital
Peninsula Regional Medical Center
Prince Georges Hospital Center
Union Memorial Hospital
Bon Secours Hospital
Good Samaritan Hospital
Howard County General Hospital
Upper Chesapeake Medical Center
Holy Cross Hospital
Anne Arundel Medical Center
Doctors Community Hospital
Baltimore Washington Medical Center
Western MD Regional Medical Center
Mercy Medical Center
Carroll Hospital Center
Northwest Hospital Center
Harford Memorial Hospital
McCready Memorial Hospital
James Lawrence Kernan Hospital
St. Mary's Hospital
Civista Medical Center
Franklin Square Hospital Center
Memorial Hospital at Easton
Shady Grove Adventist Hospital
Maryland General Hospital
Fort Washington Medical Center
Washington Adventist Hospital
Laurel Regional Hospital
Dorchester General Hospital
Atlantic General Hospital
Statewide Total
GROSS INPATIENT
CPC/CPE REVENUE
C
$184,989,402
$843,010,098
$60,653,880
$116,221,680
$151,177,296
$180,611,979
$26,318,692
$145,134,232
$783,335,558
$362,977,920
$79,741,456
$17,951,439
$248,923,504
$57,493,422
$170,650,516
$165,746,592
$209,768,089
$219,461,838
$163,205,248
$215,726,275
$70,685,898
$172,932,011
$146,791,098
$115,418,544
$276,326,064
$250,956,754
$119,486,136
$184,662,660
$159,433,379
$191,948,526
$118,189,180
$121,348,486
$42,495,040
$4,512,494
$45,850,528
$53,846,970
$60,770,370
$241,738,193
$82,689,144
$195,270,023
$105,819,110
$16,249,592
$155,015,406
$53,359,459
$28,755,684
$33,780,340
$7,451,430,205
% OF AT RISK
REVENUE FROM
EXCESS
MHAC
COMPLICATIONS RANK
D
E
0.57%
0.19%
-0.11%
-0.28%
-0.29%
-0.30%
-0.56%
-0.58%
-0.74%
-0.81%
-0.88%
-0.95%
-0.99%
-1.00%
-1.21%
-1.24%
-1.25%
-1.27%
-1.27%
-1.32%
-1.43%
-1.44%
-1.47%
-1.50%
-1.52%
-1.52%
-1.57%
-1.74%
-1.79%
-1.81%
-1.94%
-2.03%
-2.04%
-2.04%
-2.18%
-2.29%
-2.32%
-2.34%
-2.38%
-2.38%
-2.45%
-2.64%
-2.71%
-3.52%
-4.61%
-4.81%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
REVENUE
NEUTRAL
CONTINUOUS
SCALING
ADJUSTMENT
F
-2.000%
-0.667%
0.011%
0.030%
0.030%
0.031%
0.058%
0.061%
0.077%
0.084%
0.091%
0.099%
0.102%
0.104%
0.126%
0.128%
0.129%
0.131%
0.131%
0.137%
0.148%
0.150%
0.152%
0.155%
0.157%
0.158%
0.162%
0.180%
0.186%
0.188%
0.201%
0.211%
0.211%
0.211%
0.226%
0.237%
0.240%
0.243%
0.246%
0.247%
0.254%
0.274%
0.281%
0.365%
0.478%
0.499%
0.000%
Total rewards
MHAC
SCALED
REVENUE
G
-$3,699,788
-$5,624,996
$6,711
$34,321
$44,801
$56,707
$15,345
$87,916
$600,328
$305,313
$72,878
$17,763
$254,934
$59,675
$214,461
$212,423
$270,799
$287,864
$214,412
$295,490
$104,957
$258,929
$223,289
$179,397
$434,082
$396,311
$194,144
$332,979
$296,248
$361,044
$237,380
$255,679
$89,713
$9,531
$103,643
$127,748
$145,938
$586,291
$203,634
$481,892
$269,043
$44,482
$435,272
$194,922
$137,545
$168,549
$0
$9,324,784
Population Adjustment
• Relevant for TPR hospitals only
• HSCRC calculates population growth for
each hospital’s primary and secondary
service area by age cohort
• An adjustment is made to the TPR Cap in
order to account for the increase or decrease
in the population
Case Mix Index (CMI)
• All Patient Refined Diagnostic Related Grouper
• Each APR-DRG has a level of severity from 1 – 4 which is
assigned based on in depth coding information such as age,
weight, other pre-existing conditions, etc.
• 3-Level Case Mix Calculation
• Level I (CPC Included) – Hospital-specific change in CMI
• Level II (Trim) and III (Exclusions)
–
–
Revenue pass-through for exclusions and trim revenue
Statewide CMI change based on Level III
Case Mix Index (CMI)
• Calculation of Relative Weights
– Establish Statewide Average Charge per Case (with remaining data
set)
– For each Cell (DRG by Severity)
Example: Calculation of Relative Weight and CMI
State Average
State Average
DRG 002 Severity 3
$10,000
DRG 390 Severity 2
$3,000
Total State Average
$5,000
Total State Average
$5,000
Relative Weight
2.0000
0.6000
Case Mix Index (CMI)
Based on Mix of Services Provided (Case
Mix Index)
Example:
DRG Description
Normal Delivery
Chest Pain
Heart Failure
Pneumonia
Hysterectomy
Hip Replacement
Stroke
Splenectomy
Index
Weight x Cases =
0.4020
0.5342
1.0144
0.7800
0.8699
2.2500
1.1914
3.1411
Subtotal
/ Total Cases
730
490
385
385
240
273
150
3
2,656
Average CMI
Total
Index
293
262
391
300
209
614
179
9
2,257
2,656
0.850
Unit Rate Compliance
Revenue
Center
Med./Surg. Acute
New Born Nursery
Admissions
Psychiatric Day/Night
Operating Room
Radiology-Diagnostic
Renal Dialysis
$
Col. 1
Col. 2
Gross
Revenues
Units of
Measure
4,000,000
120,000
200,000
70,000
2,500,000
850,000
150,000
Col. 3
Actual
Rate
Charged
(Col 1/Col 2)
4,630 $
229
1,300
285
90,000
33,000
220
Col. 4
HSCRC
Approved
Rate
Col. 5
Charge
Variance
(Col 3-Col 4) x Col 2
863.9309 $ 854.1740 $
524.0175
518.2096
153.8462
151.7719
245.6140
252.9133
27.7778
25.2681
25.7576
26.4154
681.8182
777.9715
45,174
1,330
2,697
(2,080)
225,871
(21,708)
(21,154)
Col. 6
Variance
Percentage
(Col 3-Col 4) / Col 4
1.1%
1.1%
1.4%
-2.9%
9.9%
-2.5%
-12.4%
Hospitals must be in compliance with approved unit rates on a monthly (except TPR)
and YTD (7/1 - 6/30) basis
Unit Rate Compliance
• Although rate orders are effective July 1, hospitals usually
receive them in Oct/Nov
• Still need to be in compliance by June 30th
• Approved rate (per rate order) = $15.00
• Actual average charge for July-Dec = $10.00
• Average charge for Jan-June must = $20.00 to be in
compliance by June 30
Supply and Drug Compliance
MSS
(Supplies)
A
B
C
D
E
F
G
H
I
J
Invoice Cost
Markup Amount - per rate order
Invoice Cost with Markup
Actual Revenue
Overhead Collected
Approved Overhead - per rate order
Months of Rate Year
Approved Overhead for Period
Overhead Variance
% Variance
$
AxB
D-C
F x G / 12
E-H
I/H
2,400,000 $
1.1206
2,689,440
3,800,000
1,110,560
12,025,772
1
1,002,148
108,412
10.82%
CDS
(Drugs)
1,700,000
1.1206
1,905,020
3,100,000
1,194,980
14,813,263
1
1,234,439
(39,459)
-3.20%
CPE/CPC Price Corridors
Revenue Center
All Inpatient Room & Board
Admissions
Emergency Services
Clinic Services
Psychiatric Day/Night
Operating Room
Operating Room - Clinic
Anesthesiology
Same Day Surgery
Labor and Delivery
Laboratory
Electrocardiography
Electroencephalography
Radiology - Diagnostic
Radiology - Therapeutic
Nuclear Medicine
Monthly
Upper
Lower
10%
10%
10%
10%
4%
4%
4%
4%
4%
10%
6%
10%
6%
10%
6%
10%
4%
10%
6%
4%
6%
10%
6%
10%
6%
10%
6%
10%
6%
10%
6%
10%
Year End
Upper
Lower
10%
10%
10%
10%
2%
2%
2%
2%
2%
5%
3%
5%
3%
5%
3%
5%
2%
5%
3%
2%
3%
5%
3%
5%
3%
5%
3%
5%
3%
5%
3%
5%
Revenue Center
CT Scanner
Interventional Cardiology
Respiratory Therapy
Pulmonary
Physical Therapy
Occupational Therapy
Speech Therapy
Renal Dialysis
Audiology
MRI Scanner
Lithotripsy
Ambulance
Hyperbaric Chamber
Observation
Med/Surg Supplies
Drugs
Monthly
Upper
Lower
6%
10%
6%
10%
6%
10%
6%
10%
6%
10%
6%
10%
6%
10%
10%
10%
6%
10%
6%
10%
6%
10%
6%
10%
6%
10%
4%
4%
30%
30%
30%
30%
Year End
Upper
Lower
3%
5%
3%
5%
3%
5%
3%
5%
3%
5%
3%
5%
3%
5%
5%
5%
3%
5%
3%
5%
3%
5%
3%
5%
3%
5%
2%
2%
30%
30%
30%
30%
Overcharges/undercharges that are within the allowed corridors go into next years rates
(one time adjustment)
TPR Price Corridors
• TPR unit rate compliance corridors are more
relaxed
• Hospitals are free to charge at levels up to 5%
above / (below) the approved individual unit rates
without penalty
• This limit can be extended to 10% at the discretion
of the Commission Staff
Penalties for Exceeding the Corridors
• Penalties will be applied if rates exceed monthly
corridors for consecutive periods (TPR excluded):
– 6 consecutive months for Supplies (MSS) and
Drugs (CDS)
– 3 consecutive months for all other centers
– Penalties are calculated at 20% of the sum
(absolute value) of all charges in excess of the
corridors
– Penalties are subtracted from next years rates
Penalties for Exceeding the Corridors Cont.
• Penalties will be applied if rates exceed year-end
corridors
– Penalties are calculated at 40% of the sum
(absolute value) of all charges in excess of the
corridors
– Penalties are subtracted from next years rates
CPC and CPE Trim Exclusions
• Trim
– High charge cases
• Exclusions
– Zero and one day stay cases
– Hospice Cases
– Cases denied for medical necessity (when 100% of room and board
charges denied)
– Transplants (organ & bone)
– Other Special Cases
• Burn at Bayview
• Chronic at Kernan
• Shock Trauma
• Special Oncology
• Readmissions
Charge per Case (CPC) Compliance
Actual Revenue and Cases - YTD
Less: Exclusions
(A)
Inpatient
Revenue
$ 200,000,000
(B)
Inpatient
Cases
21,000
15,000,000
2,750
(C)
Actual CPC (A/B)
$
9,567
(D)
Actual CMI
0.9290
(E)
HSCRC CMI - per rate order
0.9310
(F)
Increase (Decrease) in CMI (D/E-1)
-0.21%
Less: Trim
1,900,000
(G)
HSCRC-Approved CPC - per rate order
$
9,627
Less: Assessments
8,500,000
(H)
Allowed CPC based on actual CMI (FxG)
$
9,606
(I)
Overcharge (undercharge) in CPC (C-H)
$
(J)
Overcharge (undercharge) in Revenue (IxB)
$ (715,322)
(K)
% Variance (I/H)
Included CPC Revenue and Cases
Actual CPC
$ 174,600,000
$
18,250
9,567
Can only adjust Inpatient Routine Centers to achieve CPC compliance
(39)
-0.41%
Charge per Episode (CPE) Compliance
Actual Revenue and Cases - YTD
$
Less: Exclusions
(A)
Inpatient
Revenue
200,000,000
(B)
Inpatient
Cases
21,000
(15,000,000)
Less: Readmissions
(C)
Actual CPE (A/B)
$
10,518
(D)
Actual CMI
1.0100
(2,750)
(E)
HSCRC CMI - per rate order
1.0120
(1,650)
(F)
Increase (Decrease) in CMI (D/E-1)
-0.20%
Less: Trim
(1,900,000)
(G)
HSCRC-Approved CPE - per rate order
$
10,607
Less: Assessments
(8,500,000)
(H)
Allowed CPE based on actual CMI (FxG)
$
10,586
(I)
Overcharge (undercharge) in CPE (C-H)
$
(J)
Overcharge (undercharge) in Revenue (IxB)
$ (1,128,223)
(K)
% Variance (I/H)
Included CPE Revenue and Cases
Actual CPE
$
174,600,000
$
16,600
10,518
Can only adjust Inpatient Routine Centers to achieve CPE compliance
(68)
-0.64%
CPC/CPE Compliance Corridors
• Overcharge Corridors:
– 0% to 1.0%
– 1.0% to 1.5%
– 1.5% to 2.0%
– 2.0% and greater
No Penalty
20% Penalty
30% Penalty
40% Penalty
• Undercharge Corridors:
– 0% to 2.0%
– 2.0 to 3.0%
– 3.0% and greater
No Penalty
40% Penalty
100% Penalty
Reasonableness of Charges
 “ROC” is the acronym for the HSCRC’s Reasonableness of
Charges
 Currently, there is no efficiency measure in place
(suspended)
 HSCRC is developing a new efficiency measure
 Several parts of the “ROC” will probably remain in the new
efficiency measure including peer groups and charge
adjustments to account for differences at each hospital.
Required Monthly Reporting
Name of Report
Volumes and Revenues
Description
Inpatient and Outpatient volumes and
revenue by rate center. Recently expanded
to report In-State vs Out of State and
Medicare
Unaudited Financial Statements Income Statement and Balance Sheet
Listing of rate centers with rates outside of
allowed corridors and plan to come into
Price variance letter, Schedule compliance, Supplemental Births, Supply &
SB, Schedeule CSS
Drug Compliance
Frequency
Due Date
Monthly
30 days after
end of month
30 days after
end of month
Monthly
30 days after
end of month
Monthly
Required Quarterly Reporting
Name of Report
Description
Inpatient Case Mix Data,
Outpatient Case Mix Data
Inpatient Hospice Report
Patient specific data including demographics,
diagnoses & procedures, financial data
Quarterly
Report patients and related charges when
100% of room & board charges are written
off for medical necessity
Quarterly
Listing of hospice patients with related
charges and payments. Not applicable to all
hospitals
Quarterly
AR1, AR2, AR3
Income, expense and utilization reporting for
Global Pricing/Capitation arrangements. Not
applicable to all hospitals
Quarterly
Denied Admissions
Frequency
Due Date
See production
schedule on
HSCRC website
45 days after end
of quarter
45 days after end
of quarter
30 days after end
of quarter
Required Annual Reporting
Name of Report
Description
Annual Cost Report
Expenses, FTE's, revenues and volume for rate centers and
HSCRC defined overhead (OH) centers. Must reconcile to
Annually
audited financial statements. OH is allocated to rate centers
Audited Financial Statements
Audited Financial Statements
Annually
Credit and Collection Policy
Hospital's Credit and Collection policy
Annually
Trustee Disclosure
AR1, AR2, AR3
Frequency
List of trustees with business addresses, individual disclosure
form for each trustee doing > $10,000 business with the
Annually
hospital
Income, expense and utilization reporting for Global
Pricing/Capitation arrangements. Not applicable to all
Annually
hospitals
Due Date
120 days after end of
fiscal year
120 days after end of
fiscal year
120 days after end of
fiscal year
120 days after end of
fiscal year
120 days after end of
fiscal year
Special Audit Report
Performed by independent auditing firm, audits various
components of the monthly, quarterly and annual reports
submitted to HSCRC. HSCRC defines the audit procedures.
Annually
140 days after end of
fiscal year
Community Benefit Report
Listing of expenses incurred providing community benefits
(direct and indirect expenses net of offsetting revenue)
Annually
December 15
Federal IRS Form 990
Interns and Residents
Wage and Salary Report
Federal IRS Form 990
Annually
Listing of interns and residents that rotated to hospital during
the FY. Includes the medical school graduated from. Not
Annually
applicable to all hospitals
Based on one pay period, groups employees into HSCRC
defined categories, calculates an average rate of pay
Annually
January 15
January 15
June 1
Terminology & Acronyms
Acronym
% Occ
What It Represents
% of Occupancy
What It Means
Calculated by dividing total patient days by (# of beds x
365 days).
ACS
Ambulatory Care Services
Services rendered to persons who are not confined
overnight in a healthcare institution. Often referred to
as “O/P” (Outpatient) services.
ACO
Accountable Care Organization
Are groups of doctors, hospitals, and other health care
providers, who come together voluntarily to give
coordinated high quality care to the Medicare patients
they serve.
ADC
Average Daily Inpatient Census
Average number of I/Ps (Inpatients) (based on the daily
inpatient census) present each day of a given period of
time.
ADM
Admission
Formal acceptance by an institution of a patient who is
provided with room and board, continuous nursing
service and other institutional services while lodged in
the institution.
APG
Ambulatory Payment Group
Classification system used to group ambulatory cases.
Terminology & Acronyms
Acronym
What It Represents
What It Means
ALOS
Average Length of Stay
Average number of days of service rendered to each I/P
discharged during a given period.
AOB
Average Occupied Beds
Total Inpatient Days divided by 365.
APR-DRG
All Payer Refined-Diagnosis Related
Group
System used by 3M Health Information Systems as the
basis of all-payer hospital payment system; used by
many hospitals in the US to analyze comparative
hospital performance.
ARR
Admission Readmission Revenue
Inpatient revenue measurement on a per episode basis.
ARMS
Alternative Rate Setting Methods
When a hospital is permitted to accept financial risk for
the provision of services under certain conditions and
circumstances.
Case Mix Index
Measure of complexity of patient population and/or
treatment provided by an institution; tells how complex
patients and services are.
CMI
Terminology & Acronyms
Acronym
What It Represents
What It Means
CMS
Center for Medicare and Medicaid
Services
The federal agency that runs the Medicare program. In
addition, CMS works with the states to run the
Medicaid program. CMS works to make sure that the
beneficiaries in these programs are able to get high
quality health care.
CON
Certificate of Need
CPC
Charge Per Case
Inpatient revenue measurement on a per case basis.
CPT
Current Procedural Terminology
Numeric coding system maintained by the American
Medical Association (AMA). Coding scheme for
outpatient procedures and services.
Formal state application and approval process for
adding new beds and services.
Terminology & Acronyms
Acronym
What It Represents
What It Means
DME
Direct Medical Education
Direct expenses (salaries, benefits, etc.) related to
qualified intern, residents and fellows in teachingrelated programs.
DSH
Disproportionate Share
EIPA
Equivalent Inpatient Admission
Statistic that combines inpatient admissions and total
outpatient visits as one unit of measure.
EIPD
Equivalent Inpatient Days
Statistic that combines inpatient days and outpatient
ambulatory visits in a weighted method.
EIPC
Equivalent Inpatient Cases
Statistic that combines inpatient cases and outpatient
ambulatory visits in a weighted method.
Providing services to a disproportionately large share of
low-income patients. Under Medicaid, states augment
payments to hospitals with high DSH. Medicare
inpatient hospital payments are also adjusted for this
added burden.
Terminology & Acronyms
Calculation of EIPAs:
Total Inpatient Revenue
Total Inpatient Admissions
Inpatient Unit Revenue
Total Outpatient Revenue
Total Outpatient Visits
Outpatient Unit Revenue
Inpatient / Outpatient Unit Ratio
$ 63,304.8 A
6,637 B
9.54 C = A / B
$ 29,845.7 D
47,274 E
0.63 F = D / E
15.11 G = C / F
Total Inpatient Admissions
6,637 H
Outpatient Visits
3,129 I
EIPAs
9,766 J = H + I
Terminology & Acronyms
Acronym
E&M
What It Represents
Evaluation and Management
What It Means
Universal codes to bill for patient visits or consultations
conducted at a clinic, emergency room or physician’s
office.
FS
Financial Statements
Balance sheet, income statement, funds statement,
statement of changes in financial position or any
supporting statement or other presentation of financial
data derived from accounting records.
FTE
Full Time Equivalents
An objective measurement of the personnel
employment of an institution in terms of full time labor
capability.
HSCRC bases FTEs on # of hours worked.
Medicare bases FTEs on # of hours paid.
Terminology & Acronyms
Acronym
GL
GME
HCPCS
What It Represents
What It Means
General Ledger
A ledger containing accounts in which all the
transactions of a business enterprise or accounting unit
are classified either in detail or in summary form.
Graduate Medical Education
Generally defined as the clinical training following
graduation from medical school. This clinical training,
which ranges from three to seven years in length
(internship and/or residency), has traditionally taken
place in teaching hospitals or academic medical centers
(AMCs). This is funded in Maryland’s rate-setting
system and is the cost of graduate medical education
(GME) generally for interns and residents trained in
Maryland hospitals.
Healthcare Common Procedure
Coding System
Alpha numeric billing codes used to identify and bill for
items and services not included in the CPT Codes.
Terminology & Acronyms
Acronym
What It Represents
What It Means
HIPAA
Health Insurance Portability and
Accountability Act
Designed for patient confidentiality, data security and
standardization.
HMO
Health Maintenance Organization
A health care provider or group of medical service
providers who contracts with insurers or self-insured
employers to provide a wide variety of managed health
care services to enrolled workers through participating
panel providers.
HSCRC
Health Services Cost Review
Commission
I/P
Inpatient
ICC
Inter-Hospital Cost Comparison
Rate-regulating and rate-setting body in the State of
Maryland.
Patient who is provided with room and board, and
continuous general nursing services in a hospital.
Defined as an admission and an overnight stay.
Cost comparison methodology used in full rate
application process.
Terminology & Acronyms
Acronym
What It Represents
What It Means
ICD-9
International Classification of
Diseases – 9th Revision Clinically
Modified
Classification of codes that represent diagnoses,
conditions and symptoms.
ICD-10
International Classification of
Diseases – 10th Revision Clinically
Modified
Classification of codes that represent diagnoses,
conditions and symptoms. October 2014
IME
Indirect Medical Education
Indirect Medical Education expenses are generally
described as those additional costs incurred as a result
of the teaching process (e.g., extra tests ordered by
interns / residents or the extra costs of supervision).
MCO
Managed Care Organization
A type of Medicare managed care plan where a group of
doctors, hospitals and other health care providers agree
to give health care to Medicare beneficiaries for a set
amount of money from Medicare every month. You
usually must get your care from the providers in the
plan.
MHA
Maryland Hospital Association
State organization of Maryland hospitals.
Terminology & Acronyms
Acronym
What It Represents
What It Means
MHCC
Maryland Health Care Commission
An independent regulatory agency whose mission is to
plan for health system needs, promote informed
decision-making, increase accountability and improve
access in a rapidly changing health care environment by
providing timely and accurate information on
availability, cost and quality of services to policy
makers, purchasers, providers and the public.
MHIP
Maryland Health Insurance Plan
State-managed health insurance program for Maryland
residents who are unable to obtain health insurance
from other sources. Each hospital is assessed at 1% of
its net patient revenue to operate the program.
NOR
Net Operating Revenue
Operating gross revenue less any contractual or other
revenue deductions.
Terminology & Acronyms
Acronym
What It Represents
What It Means
NSP
Nursing Support Program
Nursing Support Program developed to help address the
nursing workforce shortage. Each rate-regulated
hospital is eligible for a percentage of rate increase to
help pay for programs to recruit and / or retain nurses
(NSPI and NSPII).
O/P
Outpatient
Patient involved in an emergency visit, diagnostic test or
clinic visit procedure or service and is not admitted to
the hospital.
Total Allowed Revenue
Permanent revenue represents revenue that a hospital is
entitled to on a permanent and ongoing basis. The
opposite of permanent revenue is one-time revenue
which is only approved for a one year period.
PIP
Periodic Interim Payment
When a hospital receives cash payments from thirdparty payers (Usually Medicare) in constant amounts
each period. The total of these payments received over
a year is an estimated cost of providing services to
patients covered by the plan.
PLF
Price Leveling Factor
Permanent
Revenue
Factor used to inflate and / or adjust charges from a
historical / current period to a current / future period.
Terminology & Acronyms
Acronym
What It Represents
What It Means
RAC
Recovery Audit Contractor
Approved CMS contractors who have been
commissioned to review the Medicare claims of acute
care facilities to deem if services were necessary or
appropriate.
ROC
Reasonableness of Charges
(Suspended)
HSCRC’s Reasonableness of Charges Report. This
report is the Commission’s tool for assessing the
reasonableness of each hospital’s charges on a per case
basis relative to their peer group.
RVU
Relative Value Unit
Index number assigned to various procedures based
upon the relative amount of labor, supplies and capital
needed to perform the procedure. Predominantly for
ancillary activities and clinic visits (by time and
complexity).
Terminology & Acronyms
Acronym
TPR
UB-04
What It Represents
Total Patient Revenue
Uniformed Billing 2004
What It Means
An agreement which establishes a revenue cap for
qualifying hospitals. A qualifying hospital is typically
located in a rural area and has a well-defined catchment
area with a stable population.
Standard form used for the billing of facility-based /
inpatient services, effective July 2007.
UCC
Uncompensated Care
Care provided for which compensation is not received
(bad debts and charity care).
W&S
Wage & Salary Report
Job-specific pay information for hospitals. This is used
in the calculation of the Labor Market Adjustment for
HSCRC ROC and Full Rate Settings.
QBR
Quality Based Reimbursement
New HSCRC reimbursement methodology which
adjusts reimbursement for identified quality
measurements.
Terminology & Acronyms
Acronym
What It Represents
What It Means
PPC
Potentially Preventable
Complications
64 Complications that are highly preventable as defined
by 3M.
PPR
Potentially Preventable Readmissions
MHAC
Maryland Hospital Acquired
Conditions
Readmission scenarios deemed preventable.
Subset of PPC. Considered as “never events”.
P4P
Pay for Performance
Initiative which gives incentive to provider to improve
quality of care.
ODS
Zero and One-Day Length of Stay
Patients admitted and discharged by a hospital with a
length of stay less than or equal to one.
CPE
Charge per Episode
An ARR hospital’s approved revenue constraint as
determined by dividing approved included revenue by
the count of ARR Episodes of Care
QUESTIONS??