48-120.04 Diagnostic Related Group inpatient hospital fee schedule; established; applicability; adjustments; methodology; hospital; duties; reports; compensation court; powers and duties. - Nebraska Statutes

48-120.04. Diagnostic RelatedGroup inpatient hospital fee schedule; established; applicability; adjustments;methodology; hospital; duties; reports; compensation court; powers and duties.(1) This section applies only to hospitals identified in subdivision(1)(c) of section 48-120.(2) For inpatient discharges on or after January 1, 2008,the Diagnostic Related Group inpatient hospital fee schedule shall be as setforth in this section, except as otherwise provided in subdivision (1)(d)of section 48-120. Adjustments shall be made annually as provided in thissection, with such adjustments to become effective each January 1.(3) For purposes of this section:(a) Current Medicare Factor is derived from the DiagnosticRelated Group Prospective Payment System as established by the Centers forMedicare and Medicaid Services under the United States Department of Healthand Human Services and means the summation of the following components:(i) Hospital-specific Federal Standardized Amount, includingall wage index adjustments and reclassifications;(ii) Hospital-specific Capital Standard Federal Rate, includinggeographic, outlier, and exception adjustment factors;(iii) Hospital-specific Indirect Medical Education Rate, reflectinga percentage add-on for indirect medical education costs and related capital;and(iv) Hospital-specific Disproportionate Share Hospital Rate,reflecting a percentage add-on for disproportionate share of low-income patientcosts and related capital;(b) Current Medicare Weight means the weight assigned to eachMedicare Diagnostic Related Group as established by the Centers for Medicareand Medicaid Services under the United States Department of Health and HumanServices;(c) Diagnostic Related Group means the Diagnostic RelatedGroup assigned to inpatient hospital services using the public domain classificationand methodology system developed for the Centers for Medicare and MedicaidServices under the United States Department of Health and Human Services;and(d) Workers' Compensation Factor means the Current MedicareFactor for each hospital multiplied by one hundred fifty percent.(4) The Diagnostic Related Group inpatient hospital fee scheduleshall include at least thirty-eight of the most frequently utilized MedicareDiagnostic Related Groups for workers' compensation with the goal that thefee schedule covers at least ninety percent of all workers' compensation inpatienthospital claims submitted by hospitals identified in subdivision (1)(c) ofsection 48-120. Rehabilitation Diagnostic Related Groups shall not be includedin the Diagnostic Related Group inpatient hospital fee schedule. Claims forinpatient trauma services shall not be reimbursed under the Diagnostic RelatedGroup inpatient hospital fee schedule established under this section untilJanuary 1, 2012. Claims for inpatienttrauma services prior to January 1, 2012, shall be reimbursedunder the fees established by the compensation court pursuant to subdivision(1)(b) of section 48-120 or as contracted pursuant to subdivision (1)(d) ofsuch section. For purposes of this subsection, trauma means a major single-systemor multisystem injury requiring immediate medical or surgical interventionor treatment to prevent death or permanent disability.(5) The Diagnostic Related Group inpatient hospital fee scheduleshall be established by the following methodology:(a) The Diagnostic Related Group reimbursement amount requiredunder the Nebraska Workers' Compensation Act shall be equal to the CurrentMedicare Weight multiplied by the Workers' Compensation Factor for each hospital;(b) The Stop-Loss Threshold amount shall be the DiagnosticRelated Group reimbursement amount calculated in subdivision (5)(a) of thissection multiplied by two and one-half;(c) For charges over the Stop-Loss Threshold amount of theschedule, the hospital shall be reimbursed the Diagnostic Related Group reimbursementamount calculated in subdivision (5)(a) of this section plus sixty percentof the charges over the Stop-Loss Threshold amount; and(d) For charges less than the Stop-Loss Threshold amount ofthe schedule, the hospital shall be reimbursed the lower of the hospital'sbilled charges or the Diagnostic Related Group reimbursement amount calculatedin subdivision (5)(a) of this section.(6) For charges for all other stays or services that are noton the Diagnostic Related Group inpatient hospital fee schedule or are notcontracted for under subdivision (1)(d) of section 48-120, the hospital shallbe reimbursed under the schedule of fees established by the compensation courtpursuant to subdivision (1)(b) of section 48-120.(7) Each hospital shall assign and include a Diagnostic RelatedGroup on each workers' compensation claim submitted. The workers' compensationinsurer, risk management pool, or self-insured employer may audit the DiagnosticRelated Group assignment of the hospital.(8) The chief executive officer of each hospital shall signand file with the administrator of the compensation court by October 15 ofeach year, in the form and manner prescribed by the administrator, a swornstatement disclosing the Current Medicare Factor of the hospital in effecton October 1 of such year and each item and amount making up such factor.(9) Each hospital, workers' compensation insurer, risk managementpool, and self-insured employer shall report to the administrator of the compensationcourt by October 15 of each year, in the form and manner prescribed by theadministrator, the total number of claims submitted for each Diagnostic RelatedGroup and the number of times billed charges exceeded the Stop-Loss Thresholdamount for each Diagnostic Related Group.(10) The compensation court may add or subtract DiagnosticRelated Groups in striving to achieve the goal of including those DiagnosticRelated Groups that encompass at least ninety percent of the inpatient hospitalworkers' compensation claims submitted by hospitals identified in subdivision(1)(c) of section 48-120. The administrator of the compensation court shallannually make necessary adjustments to comply with the Current Medicare Weightsand shall annually adjust the Current Medicare Factor for each hospital basedon the annual statement submitted pursuant to subsection (8) of this section. SourceLaws 2007, LB588, § 2; Laws 2009, LB630, § 2; Laws 2010, LB872, § 1.