New Health Analytics MS-DRG Grouper-Calculator-Analyzer February, 12 2015
Market Problem Inpatient acute hospitals are paid based on a diagnostic severity grouping system (MS-DRG), a per stay rate. In theory, this is a simple system in which a patient stay is grouped into a category and a predetermined lump sum payment for the entire stay is provided to the hospital In reality, the coding/grouping logic is complex, and the payment made to each hospital is provider-specific and adjusted based on many factors, including location, beds, patient make up, quality reporting, performance, etc. Healthcare professionals need a simple way to understand proper coding and reimbursement under the Medicare Inpatient Prospective Payment System MS-DRG logic We need an easy way to see theoretical Medicare Expected MS-DRG Payment and the old way of keeping up a blended rate spreadsheet has become nearly impossible after the changes from the Affordable Care Act.
It s Complicated!
Solving Real Problems Demonstrate financial impact of coding reviews & CDI program Coding Consulting Company Perform batch validation and regrouping of historical claims Government Auditor Generate defensible selfpay payment rates (with outliers) Hospital Provider Understand coding, payment and market trends for service line Medical Device Manufacturer Validate Outlier payment & anticipate future payments Revenue Integrity Compare & benchmark providers, reveal ACA impact Health System Strategy
Solution: The MS-DRG Grouper A tool that simplifies MS-DRG Coding & Grouping logic and works outside of the claims system for training, validation & what-if scenarios
Solution: The MS-DRG Calculator A tool that provides instant and accurate Medicare Expected Payment for with provider-specific adjustments for all MS-DRGs with 5 years of history
Solution: The MS-DRG Analyzer A tool that extends the calculator to provide deeper payment analysis, comparisons & benchmarking, and extends the grouper to allow batch analysis of 200 claims at once
Solution: Payment Data Packages Like having the calculator to go : all payment rates for all providers in a simple excel report All MS-DRGs, all providers, rolling 20 quarters of data Allows client to look up rather than calculate, or incorporate data into their own software system or reporting infrastructure Available for Inpatient and 6 other payment systems Sold as an add-on, available in Rex view extensions (RVE) Market research underway to add enhancements to this offering, such as including additional data sources
Which Solution do I need? I need Group by ICD code Calculate Payment Suite Subscription Upgrade to the Analyzer Upgrade to Payment Data Packages Be referred to New Health Analytics Included in: Student, CRRC, ARRC, CRS, CRSP Because I also want to: Run a hundreds of claims grouping scenarios at once Perform a batch translation of ICD-9 to ICD-10 to understand the financial impact to a specific organization Included in: CRRC, ARRC, CRS, CRSP Because I also want to: Do outlier calculations Run state averages Compare base rate to ACA-adjusted rate Run what-if scenarios Calculate a contract rate Update my own system with rates Create a new offering for my clients Do product line strategy analysis For a specific subset of codes, across multiple payment systems, to bump up against other data sets, etc.
Do you know what you don t know? Beyond the standard IPPS Calculation, there are a number of ways that reimbursement can vary from what you d expect. Also, there is a need to do analysis of trending and comparisons. The Analyzer can help answer these important questions: Do you need to calculate outlier payments? Do you know how your organization stacks up against others in your network, specifically related to Medicare reimbursement? How do you verify that your contracted rates are tied to Medicare when the contract is negotiated yearly but the rates change quarterly? How do healthcare organizations (various providers) compare to benchmark payments by state, region or across the nation? Does your product line strategy include this understanding? Can you determine in advance if a specific claim will qualify for an outlier adjustment and what that payment will be? When CMS publishes changes/corrections to a provider s reimbursement variables, do you know if that will result in over or under payments?