Cost Outlier/Charge Audits. NYCHSRO/MedReview offers expert, independent medical billing audits to clients wanting to ensure that charges match actual care and services delivered. WHAT IT IS: For claims paid based on total or percent of charges or cost outliers, NYCHSRO/MedReview’s Billing and Coding compliance services focus on the following two areas.
http://web.medreview.us/our-services/audits-reviews/cost-outliercharge-audits/
Inpatient PPS Billing for Cost Outlier. Inpatient hospital claims for PPS providers in an Inpatient Hospital, Inpatient Psychiatric Unit, or Inpatient Rehabilitation Unit may end up receiving reimbursement for Cost Outlier as long as the claim has exceeded the cost outlier threshold. (This information does not apply to free-standing Psychiatric facilities).
https://med.noridianmedicare.com/web/jea/provider-types/acute-ipps-hospital/inpatient-pps-billing-cost-outlier
If the estimated cost of the short-stay outlier case exceeds the high cost outlier threshold, the short-stay outlier case. would also qualify as a high cost outlier case. For short-stay outlier cases, the outlier threshold is determined by adding.
http://library.ahima.org/xpedio/groups/public/documents/government/bok1_024253.pdf
Medicare Outlier Payments. A number of Medicare reimbursement consultants. are reportedly advising hospitals to increase routine. inpatient charges (i.e., charges for room, board, and. nursing) as a means of obtaining increased Medicare. “outlier” reimbursement.
http://www.aha.org/content/00-10/JonesDayoutlier1202.pdf
Payment Outliers. On Friday February 28, 2003, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule on payments for extremely high-cost (outlier) cases.
http://www.aha.org/advocacy-issues/medicare/outliers.shtml
Currently, hospitals qualify for outlier payments. when the hospital’s charges (adjusted by the hospital’s. cost-to-charge ratio) exceed a certain threshold amount. The outlier payment for a given inpatient equals 80. percent of difference between the hospital’s charges,
http://www.aha.org/content/00-10/JonesDayoutlier1202.pdf
HIGH COST OUTLIERS FACT SHEET. available cost report data in the Healthcare Cost Reporting Information System (HCRIS) and corresponding MedPAR. claims data from Fiscal Years (FYs) 1999, 2000, 2001, and 2002. The fixed-loss amount that is used in the calculation. for the high cost outlier payment formula results in outlier payments that are equal to 8 percent of projected total LTCH. PPS payments (i.e., the applicable short-stay outlier or full LTC-DRG payments plus high cost outlier payments).
http://library.ahima.org/xpedio/groups/public/documents/government/bok1_024253.pdf
Cost Outlier Review: For all submitted outlier payment requests, NYCHSRO/MedReview first validates that correct DRG was assigned and then whether all services were: not duplicative or erroneously billed. actually rendered. ordered by the physician. reviews for Level of Care and Quality of Care Issues.
http://web.medreview.us/our-services/audits-reviews/cost-outliercharge-audits/
outlier. 1  1 (in managed care) a case in which costs exceed the allowable amount for the specific diagnosis or treatment. 2  2 (in research) an observation that differs from all others, suggesting that a gross error has occurred in sampling, measurement, or analysis.
http://medical-dictionary.thefreedictionary.com/outlier
outlier. 1  1 (in managed care) a case in which costs exceed the allowable amount for the specific diagnosis or treatment. The outlier amount is typically specified in advance in the contract between the provider and payer.
http://medical-dictionary.thefreedictionary.com/outlier
cost outlier
The meaning of a cost outlier is a case in which costs exceed the allowable amount for the specific diagnosis or treatment.