rti international guidelines full implementation.pdf · rti international capabilities 5 • more...

RTI InternationalNicole M. Coomer, PhD

Michael Trisolini, PhD, MBA

Disclaimer

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This document has been created by or on behalf of the Dubai Health Authority (DHA). It may only be accessed, downloaded and used by Providers and Payers within the Insurance System for Advancing Healthcare in Dubai (ISAHD) network or those intending to enroll in the ISAHD network, and subcontractors of the DHA (each an Authorized User) as part of the ISAHD’s work in the Emirate of Dubai. No other individual or organization may access, download or use it without prior consent from the DHA.

The DHA is the owner or licensee of all intellectual property rights in this document, and this document is protected by copyright laws and treaties around the world. All such rights are reserved.

If the documentation or any information contained within it is used or relied upon by any person other than an Authorized User or by an Authorized User for any reason otherwise than for which it was intended, neither the DHA nor their representatives or agents will be held liable for any loss or damage arising out of such use or reliance, whether foreseeable or not. Unauthorized use may also result in the DHA taking legal action, including bringing claims for damages based on the unauthorized use.

The DHA makes no representations, warranties or guarantees of any kind whether express or implied that the content of this document is accurate, complete or up-to-date. To the extent permitted by law, we exclude all conditions, warranties, representations or other terms which may apply to this document, whether express or implied.

This disclaimer is of immediate effect from the time this document is published.

Agenda

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• RTI International Overview

• DRG Refresher

• Changes from Shadow Billing to Full Implementation

• Full Implementation DRG Parameters

• Full Implementation DRG Workbook and Performance Report

• Updates from DHA

RTI International is an independent, nonprofit research institute dedicated to

improving the human condition. We combine scientific rigor and technical

expertise in social and laboratory sciences, engineering, and international

development to deliver solutions to the critical needs of clients worldwide.

RTI International

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RTI International Capabilities

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• More than 30 years of proven expertise in

population health, health care delivery, health

care financing, data analytics, health

information technology and informatics, and

health policy and regulation.

• Use evidence-based consulting and research,

to understand what works, how it works, and

how it can be improved.

• Generate knowledge and provide greater

insight to make stronger decisions.

Agenda

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• DRG Refresher





DRG Refresher

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• The Dubai Health Authority (DHA) has adopted the International Refined Diagnosis Related Groups (DRGs) for inpatient hospital payment.

• DHA’s primary goal for health insurance payment models and

regulations is to ensure sustainability of the Dubai health system by

providing incentives for improved efficiency and quality

DRG Refresher - Overview

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• DRGs bundle or combine inpatient hospital services into a single group for each inpatient stay.

• The hospital services included in each DRG bundle represents the typical services provided across all hospitals for inpatients with similar reasons for admission.

• Each inpatient hospital stay is assigned to one and only one DRG based on the patient’s age, sex, diagnoses, procedures provided to the patient, and sometimes other factors.

DRG Refresher - Overview

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• The DRG payment system uses a series of parameters for calculating the specific payments to be made to hospitals for each inpatient stay.

Base RateRelative Weights

Outlier Payment

Components

Negotiation Band

Transfer Payments

Shadow Billing DRG Parameters

Full Implementation DRG Parameters

Base RateRelative Weights

Outlier Payment

Components

Negotiation Band

Transfer Payments

Add-On Payment

Components

DRG Refresher - Parameters

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• The base rate represents the DRG payment for the overall “average” hospital inpatient admission.

o Adjusted for budget neutrality & normalized to allow for negotiation

• Relative weights adjust the base rate for changes in the resources required to provide different hospital services as measured by the DRGs.

• Calculated by 3M using the claimed amounts in the Dubai claims data and supplemental information from Abu Dhabi.

BaseRate =Total Payments for all Inpatient Cases

Case − Mix Adjusted Number of Cases


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• The purpose of outlier payments in the DRG payment system is to provide risk sharing for very costly cases.

o Outlier Payment Components

▪ Target percentage of payments that are outlier payments (TPOP)

▪ Claim cost

▪ Marginal

▪ Threshold

• Imputing Claim Cost

• A predetermined cost for each activity code times the total number of activities billed on the claim


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• The negotiation band is the range within which health insurance companies and individual hospitals are permitted to negotiate the base rate.

o One negotiation factor is allowed per hospital/insurer combination

• Hospitals sometimes transfer patients to other hospitals

o Transfer payments allow for both hospitals treating the patient to be paid fairly for the care provided.

o Transfers of inpatients within a hospital system, where both the transferring hospital and the receiving hospital are owned by the same company, will not receive a transfer payment; only the DRG payment will be made.

Agenda

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• DRG Refresher





Changes from Shadow Billing to Full Implementation

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• Analysis data

• Inclusion of an inflation factor

• Inclusion of patient share

• Cost list updates

• Anesthesia

• Operating Room

• Add-on codes

• High cost consumable and drug add-on payments

• Updated transfer policy

Analysis Data for DRG Payment Parameter Calculation

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• Dubai claims data, from July 2015 through December 2017, from the eClaimLink system.

o Encounter Type 3 Inpatient Bed + No Emergency Room

o Encounter Type 4 Inpatient Bed + Emergency Room

where the length of stay (LOS) is greater than 0 or where LOS is 0 and the patient is discharged deceased.

Analysis Data for DRG Payment Parameter Calculation

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• Physician claims billed separately from the inpatient claim were linked to the inpatient claim by MemberID and service dates.

• Payments and claimed amounts were set as the largest line payment or claimed amount on packages with more than one line with payments greater than 0.

• Payments and claimed amounts were capped at the 1st and 99.5th percentiles

Inflation Factor

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• Claim payments and claimed amounts were increased to account for inflation from 2015 to 2018 based on claim year

• Payments and claimed amounts were updated using the 2016 and 2017 DHA Inflation Factors and general inflation for 2018:

2015 payments and claimed amounts were increased by 4.41%, then by 1.78%, and then by 2.3%.

2016 payments and claimed amounts were increased by 1.78%, then by 2.3%.

2017 payments and claimed amounts were increased by 2.3%.

Patient Share

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• Claim payments and claimed amounts were updated to include Patient Share: copayments, coinsurance, and deductibles

o Patient Share was included as recorded on the claims when present

o Patient Share was imputed based on the average percentage of payment for hospital stays that was attributable to Patient Share when missing or zero.

▪ 11% of total claim payment.

• In the future, as coding improves, the use of imputation will be phased out.

Cost List Updates

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All activity code costs for the cost list were recalculatedusing the new analysis data

The cost list has been established based on the inpatient claims data from July 2015 through December 2017.

Activity codes billed more than ten times during the period have cost set at the 25th percentile of payments*

Remaining activity codes have cost set at 1.80 times the Abu Dhabi basic price.

Codes not billed in Dubai more than 10 times and not on the HAAD price list are assigned a cost of 0 AED

The cost for drugs is set at the value on the Ministry of Health Price List.

*On average 1.80 times larger than the basic price in Abu Dhabi.

Anesthesia

• Anesthesia costs updated to use time and base units standard for Current

Procedural Terminology codes.

• Anesthesia Cost = (Base Units + Time Units) * Conversion Factor

o Conversion factor calculated using claim payments = AED 118.80

Operating Room

• Several service codes use time units.

• Conversion factor for each service code billed with time units calculated using

claim payments.

o For service codes 20 and 20.01, enter the quantity in 15-minute time

increments, e.g. 2.5 hours = 10 units.

o For all other codes with time units, follow standard coding procedures for

entering time units.

Add-on codes• The final cost list was examined to ensure that add-on CPT codes did not have

a cost greater than the primary code.

Cost List Updates

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High Cost Consumable and Drug Add-On Payments

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• Add-on payments provide risk sharing of very costly consumables and drugs that may not be fully compensated by the DRG payment.

• Calculated using a percentage of the difference between the consumable or drug documented and invoiced cost to the hospital and the drug or consumable portion of the DRG standard payment.


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• Criteria for Add-On Eligibility:

o The device or drug is on the established Dubai high cost list.

o The total cost of the specified device or drug for the claim is AED 5,000 or greater.

o The cost of the specified device or drug exceeds the specific HCPCS or drug portion of the DRG payment.

o Calculated as the inlier payment after negotiation times the HCPCS or drug DRG-specific percentage standard payment

High Cost Consumables List

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HCPCS Code Description

A4649 Surgical supply; miscellaneous. Eligible only for individual items with cost of 5000 AED or greater.

C1713 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone implantable

C1721 Cardioverter-defibrillator, dual chamber implantable

C1722 Cardioverter-defibrillator, single chamber implantable

C1731 Catheter, electrophysiology, diagnostic, other than 3D mapping 20 or more electrodes

C1732 Catheter, electrophysiology, diagnostic/ablation, 3D or vector mapping

C1776 Joint device implantable

C1781 Mesh implantable

C1785 Pacemaker, dual chamber, rate-responsive implantable

C1786 Pacemaker, single chamber, rate-responsive implantable

C1789 Prosthesis, breast implantable

C1817 Septal defect implant system, intracardiac

C1821 Interspinous process distraction device implantable

C1874 Stent, coated/covered, with delivery system

C1875 Stent, coated/covered, without delivery system

C1876 Stent, non-coated/non-covered, with delivery system

E0601 Continuous airway pressure CPAP device

E0616 Implantable cardiac event recorder with memory, activator and programmer

G0290Transcatheter placement of a drug eluting intracoronary stents, percutaneous, with or without other therapeutic

intervention, any method; single vessel

L1932Ankle foot orthosis AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting

and adjustment

L8614 Cochlear device, includes all internal and external components

S2118 Metal-on-metal total hip resurfacing, including acetabular and femoral components

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High Cost Drug List

26 Scientific Codes that map to 45 DDCs.

Scientific Code Scientific name Scientific Code Scientific name

101301-113 Paclitaxel: 100 mg Suspension for Injection 219701-080 Tenecteplase: 40 mg Powder for Injection

104301-049 Alteplase: 50 mg Infusion 219702-080 Tenecteplase: 10000 Iu Powder for Injection

111301-078Pemetrexed As Disodium Heptahydrate: 500 mg Powder

for Infusion231703-102 Pegfilgrastim: 6 mg/0.6ml Solution for Injection

126402-013 Bevacizumab: 400 mg/16ml Concentrate for Infusion 235404-080 Coagulation Factor VIIa: 1 mg Powder for Injection

176302-014Cetuximab: 5 mg/ml Concentrate for Solution for

Infusion258101-080 Infliximab: 100 mg Powder for Injection

183801-100Human Immunoglobulin: 50 mg/ml Solution for

Infusion259204-145 Lenalidomide: 25 mg Capsules Hard Gelatin

183802-100Human Immunoglobulin: 100 mg/ml Solution for

Infusion274501-013 Docetaxel: 80 mg Concentrate for Infusion

183808-100Human Immunoglobulin: 5 G/100ml Solution for

Infusion274503-013 Docetaxel: 10 mg/ml Concentrate for Infusion

195701-078 Trastuzumab: 440mg Powder for Infusion 283401-039 Valganciclovir As HCL: 450 mg Film Coated Tablets

197503-102 Adalimumab: 40 mg/0.8ml Solution for Injection 285801-013 Panitumumab: 20 mg/ml Concentrate for Infusion

202409-100Human Normal Immunoglobulin Igg, Iga: 100 mg/ml

Solution for Infusion290701-078 Trabectedin: 1 mg Powder for Infusion

214502-102 Ranibizumab: 10 mg/ml Solution for Injection 538701-102 Aflibercept: 40 mg/ml Solution for Injection

215502-013 Rituximab: 500 mg/50ml Concentrate for Infusion 580801-078 Carfilzomib: 60 mg Powder for Infusion


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• For devices and drugs meeting the criteria the add-on payment is 75% of the difference between the documented invoice cost and the HCPCS or drug portion amount built into the DRG payment.

• Hospitals will need to receive prior authorization from the health insurance company and submit invoices to document the amount paid for the high cost device or drug with the submission of the claim.

• Hospitals must also maintain documentation to support the clinical justification for use of the high cost consumable or drug.


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• Example Calculation

DRG: 146102

DRG Name: IP CESAREAN DELIVERY W/CC

HCPCS Portion of Payment (%): 8.736%

Inlier Payment following Negotiation (AED): 23,302.95

HCPCS Portion of Inlier Payment (AED): 2035.75

Total Reported Cost of High Cost HCPCS (AED): 6,000

Add on Payment; 75% X (6,000 – 2,035.75) (AED): 2,973.19


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• Inclusion of add-on payments changes the outlier formula:

Shadow Billing Formula

60% ∗ (𝐶𝑜𝑠𝑡 − 𝐼𝑛𝑙𝑖𝑒𝑟 𝑃𝑎𝑦𝑚𝑒𝑛𝑡 − 𝑇ℎ𝑟𝑒𝑠ℎ𝑜𝑙𝑑)

Full Implementation Formula

60% ∗ (𝐶𝑜𝑠𝑡 − 𝐼𝑛𝑙𝑖𝑒𝑟 𝑃𝑎𝑦𝑚𝑒𝑛𝑡 − 𝐻𝑖𝑔ℎ 𝐶𝑜𝑠𝑡 𝐴𝑑𝑑−𝑂𝑛 𝑃𝑎𝑦𝑚𝑒𝑛𝑡𝑠 − 𝑇ℎ𝑟𝑒𝑠ℎ𝑜𝑙𝑑)

Updated Transfer Payments

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• Hospitals sometimes transfer patients to other hospitals

• Payment to hospitals transferring patients to other hospitals will be a graduated per diem payment • The first hospital day will be paid the full per diem rate

• Subsequent hospital days will be paid 50% of the per diem rate.

• The per diem rate = DRG inlier payment calculated using the hospital/insurer specific negotiation factor divided by average length of stay.

Updated Transfer Payments

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• The maximum payment for any case for a patient transferred to another hospital will be the DRG inlier payment calculated with the hospital/insurer specific negotiation factor for the DRG for that hospital case.

• The receiving hospital will be paid the regular DRG payment

• Transfers of inpatients within a hospital system, where both the transferring hospital and the receiving hospital are owned by the same company, will not receive a transfer payment; only the DRG payment will be made.

Budget Neutrality

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• Budget neutrality means that, holding the number of admissions, case-mix, and other factors constant, hospitals can expect to be paid the same under DRG payment as FFS payment.

• When including outlier payments and add-on payments in the DRG payment system the Base Rate is adjusted to account for the additional outlier and add-on payments expected during a year.

Agenda

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• DRG Refresher





Dubai DRG Parameters for Full Implementation

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• Following the methods used in shadow billing along with the updates made for full implementation all payment parameters calculated:

• Base Rate

• Negotiation Band

• Relative Weights

• Outlier Payment Parameters

• Transfer Payments

• Add-On Payment Parameters

Dubai DRG Parameters for Full Implementation

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Agenda

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• DRG Refresher





Agenda

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• DRG Refresher





Ken Fan, ConsultantDubai Health Insurance Corporation

Agenda

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• Dubai Medical Coding Task Force• ICD-10-CM, CPT 4 and HCPCS Update• Dubai Medical Coding Manual• 3M CodeFinder / Grouper Software Mandate• Summary of Changes

Dubai Medical Coding Task Force (DMCTF)

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Membership:• DHIC• Top 5-6 providers by inpatient claims volume• Top 5-6 payers / TPAs by inpatient claims volume• 3M

Provider and Payer workshops will be conducted to cover the entireDubai healthcare market

Terms of Reference

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• Recommend and deploy clinical documentation and coding standards forDubai

• Develop Clinical Documentation and Coding Manuals / Guidelines /Educational Tools

• Develop clinical coding audit framework and review audit results• Recommend on coder development training courses and programs• Discuss day to day clinical documentation and coding queries• Develop clinical coding query processes and establish escalation logs /

database for Dubai• Establish clinical coding help desk and clinical coding web pages

ICD-10-CM, CPT and HCPCS Update

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“Members of DMCTF recommended to upgrade ICD-10-CM, CPT 4 and HCPCS “

Review of Dubai Medical Code Sets

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Upgrade to 2018 Version with effect from September 2019

Impact On Dubai Healthcare Market

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• No impact on 3M CodeFinder / IR-DRG Groupero Continue to use version 3.01o An update patch will be installed via 3M

• Providers and Payers to review CPT and HCPCS prices

Dubai Medical Coding Manual

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Development Process

Timeline Draft Progress

Dec 2017 1st Presented at 3rd DMCTF Meeting. Collected feedback

May 2018 2nd Includes DMCTF feedback

Oct 2018 3rd Presented 4th DMCTF Meeting. DMCTF Consensus

Apr 2019 Final Promulgations Sessions

Sep 2019 Final DHA Mandate

In claims submission:• Providers to code according to the coding standards• Payers to adjudicate according to the coding standards

3M CodeFinder / Grouper Software Mandate

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Providers:• All DHA and DHCC licensed facilities with inpatient activities

Payers:• All Insurance companies / TPAs that adjudicate inpatient claims

Summary of Changes

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Mandate with effect from September 2019:• Code sets upgrade to version 2018

o ICD-10-CMo CPT 4o HCPCS Level II

• Dubai Medical Coding Manual• 3M CodeFinder / IR-DRG Grouper Software

DHA to Issue Circular Tentatively in June 2019

rti international guidelines full implementation.pdf · rti international capabilities 5 • more...

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