42 C.F.R. § 484.240 Methodology used for the calculation of the outlier payment.
Title 42 - Public Health
(a) CMS makes an outlier payment for an episode whose estimated cost exceeds a threshold amount for each case-mix group. (b) The outlier threshold for each case-mix group is the episode payment amount for that group, the PEP adjustment amount for the episode or the total significant change in condition adjustment amount for the episode plus a fixed dollar loss amount that is the same for all case-mix groups. (c) The outlier payment is a proportion of the amount of estimated cost beyond the threshold. (d) CMS imputes the cost for each episode by multiplying the national per-visit amount of each discipline by the number of visits in the discipline and computing the total imputed cost for all disciplines. (e) The fixed dollar loss amount and the loss sharing proportion are chosen so that the estimated total outlier payment is no more than 5 percent of total payment under home health PPS.
Title 42: Public Health
PART 484—HOME HEALTH SERVICES
Subpart E—Prospective Payment System for Home Health Agencies
§ 484.240 Methodology used for the calculation of the outlier payment.
