Medicare Outlier Rule Published
March 7, 2003 - The Centers for Medicare and Medicaid
Services (CMS) March 5 published in the Federal Register [68
FR 10420] a proposed rule
that would modify the methodology for Medicare outlier payments.
Outlier payments help offset some of the financial losses
hospitals incur when treating high-cost patients.
The proposed rule would modify the outlier payment methodology
to address what CMS believes has been a "gaming"
of the outlier system which has led to larger than expected
outlier payments over the last several years. If finalized,
the rule would require the use of more recent cost-to-charge
ratios (CCRs), which are used to calculate per case costs
for purposes of determining whether a case qualifies for outlier
payments. The rule also would require a new "reconciliation"
process that would require hospitals to return excess outlier
payments if it is later determined that their per case costs
were less than what was calculated at the time the outlier
payment was made. Finally, the proposed rule would eliminate
the use of statewide CCRs for hospitals with extremely low
CCRs. Statewide averages have been viewed as one of the "gaming"
tools by hospitals seeking to increase their outlier payments.
Comments on the proposed rule are due by April 4.
Information:
Karen Fisher, Senior Associate Vice President
AAMC Health Care Affairs
kfisher@aamc.org
(202) 862-6140
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