Pricing Information 2


HOSPITAL AVERAGE CHARGE BY DIAGNOSIS RELATED GROUP (DRG)

Disclaimer:

This data is required to be posted online in machine-readable format by the Center for Medicare and Medicaid Services (CMS) Inpatient Prospective Payment System FFY 2019 rule.

The information contained here complies with federal regulations, but healthcare billing is very complex and while standard charges may be compared, hospital “charges” are not the “prices” actually paid by patients or insurers, so this information is virtually meaningless as far as what you will pay for care at FMC.

Description of information presented here:

Diagnosis Related Groups (DRGs) is a system used by CMS to pay for Inpatient Acute Care Hospital Services for Medicare beneficiaries. The entire system of DRGs used by CMS was developed specifically to address the Medicare population, and may not be accurate for use with non-Medicare patient populations.

Average charges by DRG for the 12 months ending 11/30/2018 is presented. Note there may be a very small number of cases in some DRGs, so “average charges” presented may not be a statistically valid number. DRGs with higher volumes of patients may give a better idea of what to expect as far as “total charge,” but still has little to no relevance to what an individual patient will pay. Also note that the “Average Charge” has no relevance to what will be charged to an individual patient.

A listing of DRGs can be obtained from the cms.gov web site. The listing included here uses abbreviations that while used by CMS for years, may not be easily understood by those who are not experienced in medical coding and billing. Examples of common abbreviations are CC (Complication or Comorbidity) and MCC (Major Complication or Comorbidity). These terms describe conditions that can only be known after complete information contained in the individual patient record is coded (using industry standard coding) and those codes are grouped into the DRG that is used by CMS. There are many variables in a patient’s condition that may change the final DRG from what was expected prior to admission.

The list shows the DRG Code, DRG Description, Major Diagnostic Category (MDC), MDC Description, DRG Type (Medical or Surgical), the DRG “weight” used to determine payment, and the geometric mean length of stay (GMLOS) from the CMS DRG Table applicable to the 2018 final rule as adjusted. FMC data includes the number of cases, average length of stay (ALOS) and Average Charge for all patients in the selected time frame.

Patient charges are accumulated on individual patients based on the goods and services actually received by that specific patient. Many factors (such as severity, health risk factors, etc.) can cause patient charges for patients with similar diagnoses to have different patient charges.

“Patient Charges” are not the actual “price” paid for services. Medicare and Medicaid have government-mandated fee schedules, insurers negotiate prices, and uninsured patients are eligible for significant discounts off these “list prices.”

Patient charges included in this report are only for services billed by FMC: Hospital inpatient and outpatient, Winnsboro Rural Health Clinic, Surgery Clinic and Urology Clinic.

Services provided by others such as Emergency Room physician (Island Medical), Anesthetists (Riverside Anesthesia), some radiologists (Virtual Radiology) and other providers not employed or contracted by FMC (for example local non-FMC providers) are not on this list.

Your cost of care at FMC:

The amount you are actually responsible for will vary greatly from the prices presented here based on factors related to your specific insurance coverage.

If you have Medicare:

Medicare has many different parts, and not everyone has the same type of Medicare coverage. Medicare will pay for many of your healthcare expenses but not all of them.

Diagnosis Related Groups (DRGs) is the method that Medicare uses to determine payment for an acute inpatient hospital stay. Medicare payment to FMC is not based on “patient charges,” and patient charges do not affect the amount that the patient actually owes.

Special rules apply if you have employer group health insurance coverage through your job or a spouse’s job.

If you have a supplemental health insurance policy, it may cover some costs that Medicare does not cover.

The best way to be sure of what your Medicare plan covers is to call 1-800-MEDICARE, or visit the website at www.mymedicare.gov.

If you have Medicaid:

Medicaid does not use Diagnosis Related Groups (DRGs) to determine payments, so this information does not apply to Medicaid recipients.

It should be noted that Louisiana Medicaid is developing a payment system similar to Medicare DRGs, but the diagnosis groupings will be different.

Contact your local Medicaid office at 1-888-544-7996, or visit the Louisiana Department of Health at www.http://ldh.la.gov/ to determine all the factors affecting your financial responsibility.

Generally Medicaid recipients are not responsible for any portion of the bill, but there are services that may not be covered by Medicaid.

If you have other Insurance:

Some insurers, but not all, use the Medicare DRG system to calculate payments to FMC.

Numerous factors such as the type of plan, co-pay, co-insurance, deductible, out-of-pocket maximums, provider network and other specific limitations can affect your financial responsibility.

Contact your insurance company to understand all of the factors affecting your financial responsibility.

The prices on this list do not include charges for physician or other professional fees outside of FMC providers.

The prices on this list do not include any negotiated discounts between your insurance company and the hospital.

If you have no insurance:

Franklin Medical Center offers financial assistance to patients who qualify. This policy provides discounts for uninsured patients based on their ability to pay. Please contact FMC business office at 318-412-5233 to determine if you meet the criteria for financial assistance.

The bottom line:

If you are trying to find out how much a procedure or service will cost you, whether you have insurance or not, please call us and let us give you an estimate based on your individual circumstances.

 

Download DRG Listing-2019