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Limitations

These are the stoploss types and exclusions that are currently not built out, or are awaiting a decision.

Stoploss Types​

  1. DRG ALOS Based - i.e. "Outlier payment applies when inpatient stay exceeds two times a DRG-specific Arithmetic Mean Length of stay. Additional outlier payment of of $5,6440.00 per day for each outlier day."
  2. Day Tiered - i.e. "Days 1 - 2. If billable gross charges exceed threshold of 675368.00, reimbursement will be 8528 per diem instead of the contracted rate."
  3. Both Per Diem and Percentage - i.e. "When charges for covered services exceed the 824,822 threshold, claim will be reimbursed at 47.6% of eligible charges for the entire admission. Additionally, when the length of stay exceeds 20 days during a single admission, the contract rate will be a per diem of 6,931 for each day in excess in addition to the applicable contract rate."
  4. Negotiated Rate Multiplier - i.e. "Additional Notes: If billable gross charges are less than 40% of the negotiated rate, reimbursement will be 95% of billable gross charges. If billable gross charges exceed an amount equal to 4.5 times the negotiated rate, reimbursement shall be 46.5% of billable gross charges instead of the contracted rate". Similar base rate one - "Reimbursed at 50% when 250% threshold over base rate is met"
  5. Service Type Split - i.e. "Reimbursed at 69% of billed charges when outlier threshold of 175,000forCardiacor175,000 for Cardiac or 150,000 for all other inpatient is exceeded."
  6. Lesser of Language - i.e. "If billable gross charges exceed threshold of 221410.00,reimbursementwillbethelesserof(a)25.2221410.00, reimbursement will be the lesser of (a) 25.2% of billable gross charges, or (b) 7713 multiplied by the number of medically necessary days."
  7. Medically Necessary Days - i.e. "If billable gross charges exceed threshold of 221410.00,reimbursementwillbethelesserof(a)25.2221410.00, reimbursement will be the lesser of (a) 25.2% of billable gross charges, or (b) 7713 multiplied by the number of medically necessary days."

Exclusions​

  1. Catalog of MS-DRGs that are excluded from stoploss
  2. Implant carveouts
  3. Drug carveouts
  4. General Y/N pass through

Outstanding Decisions & Questions​

  1. Are we comfortable assuming ambiguous notes are first dollar? i.e. "Charges greater than $200,000 paid at 50% of charges"
  2. How should we handle discount language? i.e. "Stop-loss discount of N percent applies when charges exceed N"
  3. What does "outlier threshold factor" mean? i.e. "Reimbursed at 18% of billed charges when outlier threshold factor of 9.5 is met"
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