Reducing Resources (Days and Charges)

Resources are defined by the length of stay (days) or total charges associated with a claim. As a claim is processed, the resources are reduced. When all resources are consumed, the system stops repricing that claim.

When service types are added to a profile, you must specify how those resources are reduced, by days or charges:

• Days Expression – Reduces resources by days (inpatient).
• Charges Expression – Reduces resources by charges (outpatient).

Days Expression

Because inpatient claims are billed by days, you typically use the days expression to reduce those resources.

Type of Reimbursement	Days Expression	System Interpretation
Case-based	9999	Reimburses the service type and consumes all remaining days
Line-item	RevDays	Reimburses the highest ranking service type and continues processing until all resources are consumed Note: Use the plus (+) operator to sum multiple line-item values. (e.g. RevDays 214 + RevDays 206)

Note: All IP, Med and MedSurg are typically the default service types for services that have not been specifically negotiated. For these service types, use 9999 in the days expression.

Level of Care

Level of Care (LOC) refers to Medical, Surgical, DOU, ICU, or CCU levels that apply with a corresponding per diem rate. LOC indicates that the per diem rate that applies to the patient's level of care will be reimbursed (in addition to the case rate) for each day a patient needs to stay due to their clinical condition that exceeds the number of days included in the case rate. These days may include patient days required either pre-op or post-op.

The LOC days can start from the start of the claim, the procedure date, or the primary procedure date. If you select the procedure date or primary procedure date, you must either enter the procedure code to use in the Procedure code field or select a procedure lookup table from the Lookup table list.

Charges Expression

Because outpatient claims are billed by charges, you typically use the charges expression to reduce those resources.

Type of Reimbursement	Charges Expression	System Interpretation
Case-based	9999999	Reimburses the service type and consumes all remaining resources
Line-item	RevCharges ProcCharges	Looks for the highest ranking service type and continues processing until all resources are consumed Note: Use the plus (+) operator to sum multiple line-item values. (e.g. RevCharges 610 + RevCharges 611)

Note: All OP is the default service type for services that have not been specifically negotiated. Use 9999999 in the charges expression.

Review the following example, which outlines a simple scenario of reducing resources.

Inpatient Claim

Total length of stay = 4 days

Service Type	Length of Stay	Reimbursement	Universal Rank
DOU	2 days	$1000 per day	70
Telemetry	2 days	$1100 per day	65

If you want this claim to qualify for all of these service types then your days expression must be RevDays 206 + RevDays 214.

For this example, the total available resources is 4 days, the length of stay (if this example was an outpatient and the resource reduction was based on charges, then the total available resources would equal billed charges). Because there are multiple service types available, FinThrive checks the rank to determine which service type to reimburse first. In this case it would qualify for the telemetry service type, because it has a higher priority ranking.

At this point, the system takes the total available resources (4) then subtracts the resources associated with the days expression for telemetry (in this case 2, because RevDays 214 equals 2).

Because there are additional resources available for consumption, the system checks the next service type it matches based on the condition expression in the next ranking order. In this example it then matches DOU and consumes the 2 remaining days.