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Rates and Weights

Hospital Rates and Weights

Note: This Portal page was formerly titled Inpatient & Outpatient Hospital Rates and Inpatient Hospital Weights.

The All Patient Refined Diagnosis Related Group (APR DRG) rates and weights, the Medicare Severity Diagnosis Related Group (MS-DRG) weights and rates, Enhanced Ambulatory Patient Group (EAPG) weights and rates, and outpatient hospital rates per visit are available in the tables on this Portal page. The MS-DRG classification system is still effective for inpatient hospital claims, Medicare crossover claims, and HMO encounters with dates of discharge or “To” DOS before January 1, 2017.

Click the following links for overviews of how pricing for hospital services is determined:

Current System Information
PRODUCT Version Installation Date
3M Grouper Plus System (GPS) 2021.2.1 9/5/2021
APR DRG Grouper 37.1 1/1/2021
EAPG Grouper 3.15 1/1/2021


Archived Inpatient and Outpatient Rates and Weights

Note: Inpatient Hospital DRG Rates and Weights and Outpatient Hospital Rates follow rate setting year cycles.

Inpatient Hospital DRG Rates
(including outlier trimpoint and access payment rate information).
Rates Effective 1/1/2022
PDF
Rates Effective 1/1/2022
Excel
Rates Effective 1/1/2021
PDF
Rates Effective 1/1/2021
Excel
Rates Effective 1/1/2020
PDF
Rates Effective 1/1/2020
Excel
Inpatient Hospital DRG Weights
Weights Effective 1/1/2022
PDF
Weights Effective 1/1/2022
Excel
Weights Effective 1/1/2022
Text Format
The DRG weights in the .txt format should be used for the 3M option.
Weights Effective 1/1/2021
PDF
Weights Effective 1/1/2021
Excel
Weights Effective 1/1/2021
Text Format
The DRG weights in the .txt format should be used for the 3M option.
Weights Effective 1/1/2020
PDF
Weights Effective 1/1/2020
Excel
Weights Effective 1/1/2020
Text Format
The DRG weights in the .txt format should be used for the 3M option.

Outpatient Hospital Enhanced Ambulatory Patient Groups (EAPG) Rates
(including access payment rate information).

EAPG Rates Effective 1/1/2022
PDF

EAPG Rates Effective 1/1/2022
Excel

EAPG Rates Effective 1/1/2021
PDF

EAPG Rates Effective 1/1/2021
Excel

EAPG Rates Effective 1/1/2020
PDF

EAPG Rates Effective 1/1/2020
Excel

Outpatient Hospital Enhanced Ambulatory Patient Groups (EAPG) Weights
Text Format
For 3M Software use
Microsoft Excel Format
Not for 3M Software use
Effective 1/1/2022 Effective 1/1/2022
Effective 1/1/2021 Effective 1/1/2021
Effective 1/1/2020 Effective 1/1/2020
The EAPG weights appear in two formats, Text (.txt) and Microsoft Excel (.xlsx). The EAPG weights in the .txt format should be used for the 3M option. As a professional courtesy, ForwardHealth is also offering the EAPG weights in an Excel decimal place version.

Note: the Excel version cannot be imported into the 3M software, i.e., you must use the .txt version for 3M software.
Medicaid Outpatient Hospital Rates-per-visit (only apply to County Jail Inmates)

Outpatient Per Visit Rates
Effective 1/1/2021
PDF

Outpatient Per Visit Rates
Effective 1/1/2021
Excel

Outpatient Per Visit Rates
Effective 1/1/2020
PDF

Outpatient Per Visit Rates
Effective 1/1/2020
Excel

Cost Center Crosswalks and DRG Enhancement Tables

  • Rate Year 2021 Outpatient Revenue Code Crosswalk to Suggested Cost Centers — Excel | PDF
  • Rate Year 2020 Outpatient Revenue Code Crosswalk to Suggested Cost Centers — Excel | PDF
  • Rate Year 2019 Outpatient Revenue Code Crosswalk to Suggested Cost Centers — Excel | PDF
  • Rate Year 2018 Outpatient Revenue Code Crosswalk to Suggested Cost Centers — Excel | PDF
  • Rate Year 2017 Outpatient Revenue Code Crosswalk to Suggested Cost Centers — Excel | PDF
  • Rate Year 2021 Inpatient Revenue Code Crosswalk to Suggested Cost Centers — Excel | PDF
  • Rate Year 2020 Inpatient Revenue Code Crosswalk to Suggested Cost Centers — Excel | PDF
  • Rate Year 2019 Inpatient Revenue Code Crosswalk to Suggested Cost Centers — Excel | PDF
  • Rate Year 2018 Inpatient Revenue Code Crosswalk to Suggested Cost Centers — Excel | PDF
  • Rate Year 2017 Inpatient Revenue Code Crosswalk to Suggested Cost Centers — Excel | PDF
  • Inpatient Hospital DRGs for Mental Diseases and Disorders Crossover Chart from Medicare (T18) DRG to Wisconsin Medicaid DRGs — Excel | PDF

Overview of APR DRG Pricing

For dates of discharge or "To" dates of service (DOS) on and after January 1, 2017, ForwardHealth groups and prices claims using the APR DRG classification system. The APR DRG rates and weights are updated and published annually. In accordance with federal regulations, Wisconsin provides public notice and an opportunity for written, public comments regarding the proposed hospital reimbursement methodology, inpatient hospital rates, and inpatient hospital weights prior to final approval by the federal Department of Health and Human Services. Current inpatient hospital APR DRG rates and weights and archived inpatient hospital weights and rates are available.

A more detailed description of rate-setting can be found in the Wisconsin Medicaid inpatient and outpatient state plans. Additional APR DRG information, including ForwardHealth updates, training materials, and the APR DRG pricing calculator can be found here.

Note: For dates of discharge or "To" DOS prior to January 1, 2017, ForwardHealth continues to group and price using the Medicare Severity Diagnosis Related Groups (MS-DRG) classification system.


APR DRG Weights

ForwardHealth applies the 3M™ APR DRG grouper and corresponding 3M™ national weights to each APR DRG. These weights reflect the relative resource consumption of each inpatient stay. For example, the average hospitalization with a DRG weight of 1.5 would consume 50% more resources than the average hospitalization with a weight of 1.0; a hospital stay assigned a DRG with a weight of .5 would require half the resources.


Hospital Inpatient Base Rate Effective January 1, 2017

ForwardHealth calculates and assigns a payment rate, per inpatient discharge, to each hospital for the rate year. This calculation determines a unique "hospital-specific APR DRG base rate" for the hospital. The hospital-specific APR DRG base rate includes an adjustment for differences in wage and labor levels among rural and metropolitan areas throughout the state. This rate also includes amounts for direct costs of a medical education program.

Payment to a hospital for a member’s hospital stay is calculated by multiplying the hospital’s specific APR DRG base rate by the weight assigned to the DRG into which the stay is classified by the grouper.


Inpatient Access Payments

To promote members access to acute care hospitals, children’s hospitals, and rehabilitation hospitals throughout Wisconsin, ForwardHealth provides a hospital access payment amount per inpatient discharge. Access payments are intended to reimburse hospital providers based on Wisconsin Medicaid utilization. Therefore, the payment amounts per discharge are not differentiated by hospital based upon acuity or individual hospital cost.

The amount of the hospital access payment per discharge is based upon available funding appropriated in the state budget and aggregate hospital upper payment limit (UPL). The amount of funding is divided by the estimated number of paid inpatient discharges for the state fiscal year. The payment per discharge is in addition to the APR DRG and per diem payments for Wisconsin acute care hospitals, children’s hospitals, and rehabilitation hospitals. Access payments per discharge are only provided until the fee-for-service hospital access payment budget has been expended for the state fiscal year.


Cost Outlier Payments

A cost outlier payment is made when the cost of providing a service exceeds a pre-determined trim point. Each inpatient hospital claim is tested to determine whether the claim qualifies for a cost outlier payment.

Overview of EAPG Pricing

ForwardHealth used the EAPG classification system to calculate pricing for outpatient hospital claims. Using the EAPG classification system, reimbursement for outpatient hospital services is based upon the quantity and type of services provided. The EAPGs ensure that both low- and high-cost services are reimbursed appropriately. The EAPG reimbursement methodology applies to fee-for-service members enrolled in BadgerCare Plus, Wisconsin Medicaid, and the Wisconsin Chronic Disease Program.


Weight Calculation Effective January 1, 2017

Effective January 1, 2017, ForwardHealth applies the 3M EAPG national weights. Prior to that date, ForwardHealth applied state-specific weights. See History page.

Hospital Outpatient Base Rate

The base rate for critical access hospitals is a prospective cost-base rate, established using the most recently available Medicare Cost Report.

The critical access hospital base rate is calculated as follows:

Provider’s Total Cost ÷ Provider’s Total Adjusted Weights = Critical Access Hospital Base Rate

The base rate for all other hospitals paid under the EAPG reimbursement methodology was calculated from the remaining DHS outpatient hospital budget and the total adjusted EAPG weights for all other providers:

DHS Outpatient Hospital Budget (less critical access hospital and lab payments) ÷ Total Adjusted EAPG Weights = Hospital Base Rate

Additional Information

For additional information, contact:

Division of Medicaid Services
Bureau of Fiscal Management
1 W Wilson, Rm 350
PO Box 309
Madison WI 53701-0309
Telephone – 608-266-8922
Email – DHSDMSBFM@wi.gov
FAX – 608-266-1096

 
 
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