Inpatient Prospective Payment System

Overview

Inpatient Services provided by in-state hospitals enrolled in Georgia Medicaid are reimbursed through the Inpatient Prospective Payment System (IPPS). Under IPPS, claims are categorized into a diagnosis-related group (DRG) for payment purposes by the APR DRG grouper software within the Georgia Medicaid Management Information System (GAMMIS). Each DRG has a payment weight assigned to it, calculated from the average cost to treat patients with conditions that fall into that DRG.

Out-of-state hospitals enrolled in Georgia Medicaid program are paid at the state-wide base rate for inpatient services and the state-wide cost-to-charge rate for outpatient services.

Hospital Specific Base Rate Calculation:

The Hospital Specific Base Rate will include adjustments for each hospital’s Medicaid Inpatient Utilization Rate (MIUR), Indirect Medical Education (IME) if applicable, Peer Group Add-On Amount if applicable, and a stop-loss/stop-gain adjustment if applicable.

The Hospital Specific Base Rate is calculated as: [((Statewide Base Rate) x (1+MIUR Factor) x (1+IME Factor)) + (Peer Group Add-On Amount)] x (1+ Stop-Loss/Stop Gain Adjustment)

Hospital All Patient Refined Diagnostic Group

Effective January 1, 2024, IPPS claims are categorized using the APR DRG grouper for claims payment purposes.

All Patients Refined Diagnosis Related Groups (APR DRG) is a classification system that classifies patients according to their reason of admission, severity of illness and risk of mortality.

- - The patient characteristics used in the definition of the DRGs are limited to information routinely collected on hospital abstract systems.
  - There are a manageable number of DRGs which encompass all patients seen on an inpatient basis.
  - Each DRG contains patients with a similar pattern of resource intensity.
  - Each DRG contains patients who are similar from a clinical perspective.