A classification system used in healthcare to group patients with similar diagnoses and procedures for the purpose of reimbursement. DRGs help standardize payments to hospitals based on the resources required to treat a patient’s condition.
Refers to the variety and complexity of patients treated within a healthcare facility, as determined by factors such as diagnoses, procedures, and patient demographics. DRGs are used to adjust reimbursement rates according to case mix.
A reimbursement method where predetermined rates are established for specific services or conditions, such as DRGs. PPS aims to control healthcare costs by setting fixed payments in advance.
The process of assigning numeric or alphanumeric codes to diagnoses, procedures, and treatments according to standardized systems such as ICD-10 (International Classification of Diseases) and CPT (Current Procedural Terminology). Accurate coding is crucial for proper DRG assignment.
A measure of the extent of physiological decompensation or organ system loss of function in a patient’s condition. SOI is often used alongside DRGs to adjust reimbursement rates based on the severity of the patient’s illness.
The allocation and consumption of healthcare resources, including staff time, equipment, medications, and facilities, in the treatment of patients. DRGs aim to account for variations in resource utilization across different patient groups.
Additional payments made to hospitals for treating patients with unusually high costs or complex conditions that exceed the standard reimbursement rate for their DRG. Outlier payments help ensure fair compensation for hospitals handling exceptional cases.
Illegal or unethical practices aimed at manipulating DRG coding and billing processes to obtain higher reimbursements or payments for services not rendered. Healthcare providers must adhere to strict compliance standards to prevent fraud and abuse.
Performance indicators used to assess the effectiveness, safety, and patient outcomes of healthcare services provided by hospitals. DRGs may incentivize hospitals to focus on improving quality metrics to optimize reimbursement and patient care.
A healthcare delivery model that emphasizes achieving better patient outcomes and reducing costs by incentivizing providers to deliver high-quality care efficiently. DRGs play a role in the shift towards value-based reimbursement models by aligning payments with patient outcomes and resource efficiency.