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Minnesota Department of Labor and Industry

Workers' compensation -- PC Pricer tool for inpatient hospital bills



In 2015, Minnesota Statutes § 176.1362 was enacted to provide that the maximum payment for most workers' compensation inpatient hospital services is 200 percent of the amount calculated under the Medicare diagnosis-related group (DRG) system, using Medicare's PC Pricer program.

Effective May 31, 2017, Minn. Stat. § 176.1362 was amended to identify the applicable PC Pricer program to be used to calculate payment for inpatient hospital services.

For hospital discharge dates from May 31 through Sept. 30, 2017:  The FY 2016.1 PC Pricer, updated Jan. 19, 2016, must be used to calculate the amount payable.

For hospital discharge dates on or after Oct. 1, 2017:  The FY 2017.0 PC Pricer, updated April 24, 2017, must be used to calculate the amount payable. (This is the PC Pricer program most recently available on the Medicare website as of July 1, 2017.)

No later than Oct. 1 of each subsequent year, the Department of Labor and Industry (DLI) must post on its website the version of the PC Pricer program that is most recently available on Medicare's website as of the preceding July 1. DLI will publish notice of the applicable program in the State Register no later than Oct. 1 of each year. If Medicare does not update the PC Pricer program, the version most recently posted on DLI's website remains in effect.

Pricing inpatient hospital bills for dates of service from Oct. 1, 2017 through Sept. 30, 2018

The law directs payers to calculate the amount payable for inpatient hospital services using the PC Pricer program posted on the department’s web site, in this case the FY 2017.0 PC Pricer. However, because Medicare's payment year is from Oct. 1 through Sept. 30, the PC Pricer used in Minnesota workers’ compensation in effect Oct. 1, 2017, will not price discharges on or after Oct. 1, 2017.

The solution for discharges occurring from Oct. 1, 2017, through Sept. 30, 2018, is to enter the discharge as one year prior to the date of service into the PC Pricer, with the same month and day portions of the dates of service. For example, an inpatient bill with dates of service from Nov. 1, 2017 to Nov. 10, 2017, should be entered in the Pricer as Nov. 1, 2016, to Nov. 10, 2016, and an inpatient bill with dates of service from Feb. 3, 2018, to Feb. 7, 2018, should be entered in the Pricer as Feb. 1, 2017, to Feb. 7, 2017.

The PC Pricer will then calculate the amount that would be paid by Medicare using the FY 2017.0 Pricer, as directed by the law.

Additional information about inpatient hospital payments for Minnesota workers' compensation

Hospital catastrophic injury threshold amounts

  • Statute:  Minnesota Statutes section 176.1362, subd. 2

  • Discharges from Jan. 1, 2016, through Dec. 31, 2016:  $175,000

  • Discharges from Jan. 1, 2017, through Sept. 30, 2017:  $183,523

  • Discharges from Oct. 1, 2017, through Sept. 30, 2018:  $196,021

 

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