The CMS published criteria that will trigger a review of hospitals for suspected abuse of the outlier payment system. The three main criteria are: fiscal 2003 outlier payments equal to at least 10% of a hospital's total Medicare payments; a 20% or greater single-year increase in outlier payments within the past two years; or a 15% or greater single-year increase in average per-case charges within the past two years. The CMS is expected to publish by July 31 a final inpatient payment rule for 2004 with a new outlier threshold. The proposed threshold is $50,645 above the DRG payment, compared with the current threshold of $33,560. Outlier payments, which compensate hospitals for especially costly cases, became a source of controversy following disclosure last fall that Tenet Healthcare Corp.'s profits depended in part on significantly higher outlier revenue than the industry average. -- by Jeff Tieman
CMS lists causes for outlier-payment investigations
Send us a letter
Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.