§ 48-120.04 — Diagnostic Related Group inpatient hospital fee schedule; trauma services inpatient hospital fee schedule; established; applicability; adjustments; methodology; hospital; duties; reports; compensation court; powers and duties

Nebraska § 48-120.04

• Jurisdiction: Nebraska
• Ch. 48: Labor

Text

(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 set
forth in this section, except as otherwise provided in subdivision (1)(d)
of section 48-120 . Adjustments shall be made annually as provided in this
section, with such adjustments to become effective each January 1.
(3) For inpatient
trauma discharges on or after January 1, 2012, the trauma services inpatient
hospital fee schedule shall be as set forth in this section, except as otherwise
provided in subdivision (1)(d) of section 48-120 . Adjustments shall be made
annually as provided in this section, with such adjustments to become effective
each January 1.
(4) For
purposes of this section:
(a) Current Medicare Factor is derived from the Diagnostic
Related Group Prospective Payment System as established by the Centers for
Medicare and Medicaid Services under the United States Department of Health
and Human Services and means the summation of the following components:
(i) Hospital-specific Federal Standardized Amount, including
all wage index adjustments and reclassifications;
(ii) Hospital-specific Capital Standard Federal Rate, including
geographic, outlier, and exception adjustment factors;
(iii) Hospital-specific Indirect Medical Education Rate, reflecting
a 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 patient
costs and related capital;
(b) Current Medicare Weight means the weight assigned to each
Medicare Diagnostic Related Group as established by the Centers for Medicare
and Medicaid Services under the United States Department of Health and Human
Services;
(c) Diagnostic Related Group means the Diagnostic Related
Group assigned to inpatient hospital services using the public domain classification
and methodology system developed for the Centers for Medicare and Medicaid
Services under the United States Department of Health and Human Services;
(d) Trauma
means a major single-system or multisystem injury requiring immediate medical
or surgical intervention or treatment to prevent death or permanent disability;
(e) Workers' Compensation
Factor means the Current Medicare Factor for each hospital multiplied by one
hundred fifty percent except
for inpatient hospital trauma services; and
(f) Workers'
Compensation Trauma Factor for inpatient hospital trauma services means the
Current Medicare Factor for each hospital multiplied by one hundred sixty
percent.
(5) The Diagnostic Related
Group inpatient hospital fee schedule shall include at least thirty-eight
of the most frequently utilized Medicare Diagnostic Related Groups for workers'
compensation with the goal that the fee schedule covers at least ninety percent
of all workers' compensation inpatient hospital claims submitted by hospitals
identified in subdivision (1)(c) of section 48-120 . Rehabilitation Diagnostic
Related Groups shall not be included in the Diagnostic Related Group inpatient
hospital fee schedule. Claims for inpatient trauma services shall not be reimbursed
under the Diagnostic Related Group inpatient hospital fee schedule established
under this section. Claims
for inpatient trauma services prior to January 1, 2012, shall be reimbursed
under the fees established by the compensation court pursuant to subdivision
(1)(b) of section 48-120 or as contracted pursuant to subdivision (1)(d) of
such section. Claims
for inpatient trauma services on or after January 1, 2012, for Diagnostic
Related Groups subject to the Diagnostic Related Group inpatient hospital
fee schedule shall be reimbursed under the trauma services inpatient hospital
fee schedule established in this section, except as otherwise provided in
subdivision (1)(d) of section 48-120 .
(6) The trauma
services inpatient hospital fee schedule shall be established by the following
methodology:
(a) The trauma services reimbursement amount required under the
Nebraska Workers' Compensation Act shall be equal to the Current Medicare
Weight multiplied by the Workers' Compensation Trauma Factor for each hospital;
(b) The Stop-Loss
Threshold amount shall be the trauma services reimbursement amount calculated
in subdivision (6)(a) of this section multiplied by one and one-quarter;
(c) For charges
over the Stop-Loss Threshold amount of the schedule, the hospital shall be
reimbursed the trauma services reimbursement amount calculated in subdivision
(6)(a) of this section plus sixty-five percent of the charges over the Stop-Loss
Threshold amount; and
(d) For charges less than the Stop-Loss Threshold amount of the
schedule, the hospital shall be reimbursed the lower of the hospital's billed
charges or the trauma services reimbursement amount calculated in subdivision
(6)(a) of this section.
(7) The
Diagnostic Related Group inpatient hospital fee schedule shall be established
by the following methodology:
(a) The Diagnostic Related Group reimbursement amount required
under the Nebraska Workers' Compensation Act shall be equal to the Current
Medicare Weight multiplied by the Workers' Compensation Factor for each hospital;
(b) The Stop-Loss Threshold amount shall be the Diagnostic
Related Group reimbursement amount calculated in subdivision (7)(a) of
this section multiplied by two and one-half;
(c) For charges over the Stop-Loss Threshold amount of the
schedule, the hospital shall be reimbursed the Diagnostic Related Group reimbursement
amount calculated in subdivision (7)(a) of this section plus
sixty percent of the charges over the Stop-Loss Threshold amount; and
(d) For charges less than the Stop-Loss Threshold amount of
the schedule, the hospital shall be reimbursed the lower of the hospital's
billed charges or the Diagnostic Related Group reimbursement amount calculated
in subdivision (7)(a) of this section.
(8) For charges for all other
stays or services that are not reimbursed under the Diagnostic
Related Group inpatient hospital fee schedule or the trauma services inpatient hospital fee schedule or
are not contracted for under subdivision (1)(d) of section 48-120 , the hospital
shall be reimbursed under the schedule of fees established by the compensation
court pursuant to subdivision (1)(b) of section 48-120 .
(9) Each hospital shall assign
and include a Diagnostic Related Group on each workers' compensation claim
submitted. The workers' compensation insurer, risk management pool, or self-insured
employer may audit the Diagnostic Related Group assignment of the hospital.
(10) The chief executive officer
of each hospital shall sign and file with the administrator of the compensation
court by October 15 of each year, in the form and manner prescribed by the
administrator, a sworn statement disclosing the Current Medicare Factor of
the hospital in effect on October 1 of such year and each item and amount
making up such factor.
(11) Each hospital, workers'
compensation insurer, risk management pool, and self-insured employer shall
report to the administrator of the compensation court by October 15 of each
year, in the form and manner prescribed by the administrator, the total number
of claims submitted for each Diagnostic Related Group, the number of claims for each Diagnostic Related Group
that included trauma services, the
number of times billed charges exceeded the Stop-Loss Threshold amount for
each Diagnostic Related Group,
and the number of times billed charges exceeded the Stop-Loss Threshold amount
for each trauma service.
(12) The compensation court
may add or subtract Diagnostic Related Groups in striving to achieve the goal
of including those Diagnostic Related Groups that encompass at least ninety
percent of the inpatient hospital workers' compensation claims submitted by
hospitals identified in subdivision (1)(c) of section 48-120 . The administrator
of the compensation court shall annually make necessary adjustments to comply
with the Current Medicare Weights and shall annually adjust the Current Medicare
Factor for each hospital based on the annual statement submitted pursuant
to subsection (10) of this section.

Legislative History

Source: Laws 2007, LB588, § 2; Laws 2009, LB630, § 2; Laws 2010, LB872, § 1; Laws 2011, LB152, § 2.