What is the DRG reimbursement for this case?

Question

You're reviewing reimbursement for a Medicare case. The case falls into DRG 1, which has a relative weight of 3.0970, geometric mean length of stay of 6.3. The hospital's reimbursement rate is $1500. What is the DRG reimbursement for this case?

Answer 1

Technically, there isn't enough information to accurately answer this question.  

For example, you didn't state the billed charges on the claim or the patient's actual length of stay...without those pieces of information, you can't tell whether the patient would be a cost outlier or a day outlier.  Also, many hospitals get capital, medical education, disproportionate share (DSH) and other allowances on top of the basic DRG rate.

That being said, the way to calculate a basic DRG rate is the base rate X the relative weight.

So...going strictly on the information you provided, the answer would be $4,645.50.  (3.0970 times $1,500)

If this is for a homework assignment, $4,645.50 should be a sufficient answer.  

If you're actually trying to figure out what reimbursement would be on a real world example, you'd need to know whether the patient was an outlier or whether the hospital had additional allowances for capital, medical education, DSH (disproportionate share), etc.  CMS has an Inpatient PPS pricer that you can download free from the Medicare website...all you need is the hospital's Medicare number to calculate an exact DRG payment.