Hospital Payment Policy
Inpatient acute care hospital services are reimbursed on a prospective basis using the All Patient Refined Diagnosis Related Group (APR-DRG) system. Outpatient acute care and ambulatory surgical center (ASC) services are reimbursed on a prospective basis using the Enhanced Ambulatory Patient Groups (EAPG) system. A small portion of hospital services provided in freestanding rehabilitation or long term hospitals, in hospitals which are licensed as HMOs, and in cancer hospitals are not subject to APR-DRG or EAPG reimbursement.
The billing guidelines for hospitals and ASCs are available on the ODM Guidance webpage.
Under the APR-DRG system, hospitals are reimbursed based on the principal diagnosis or condition requiring the hospital admission. The APR-DRG system is designed to classify patients into groups that are clinically coherent with respect to the amount of resources required to treat a patient with a specific diagnosis. Applicable additional payments are added for capital, medical education, and outliers.
Ohio chose to use this system in an effort to contain costs, to permit providers to operate in a less regulated environment, and to allow sharing of savings for those providers who identify ways to provide quality services more efficiently and economically. Just as hospitals do not get more than their fixed payment if the APR-DRG amount is less than charges, their APR-DRG payment rate is not lowered to match the billed charge amount.
Under the EAPG system, outpatient hospital and ASC facility claims are reimbursed based on the principal diagnosis and procedure codes submitted for a date of service. The EAPG system is designed to classify services into groups that utilize similar resources and have similar costs. The EAPG system also applies discounting factors which could cause a detail line to consolidate, package, or discount.
With the implementation of the EAPG system, Ohio moves away from prospectively determined fee schedule rates. The EAPG reimbursement methodology enables the department to cover new procedure codes more efficiently as the EAPG system maps the new procedure codes to a specific EAPG, which already have established relative weights.
Ohio has implemented 3M’s All Patient Refined Diagnosis Related Groups (APR-DRG). It is the Department’s intent to stay current with grouping software releases. Regardless of the APR-DRG Grouper Version in use, hospitals are expected to always bill using the diagnosis and procedure codes that were in effect as of the date of discharge.
Ohio has implemented 3M's Enhanced Ambulatory Patient Groups (EAPG) system for outpatient and ASC facility claims. Regardless of the EAPG Grouper Version in use, providers are expected to always bill using the diagnosis and procedure codes that were in effect as of the date of service.