A client is admitted with chest pain. A series of diagnostic tests are ordered, and the client undergoes coronary artery bypass grafting
The cost of care for this client is increased because of a four-pack-per-day smoking history that resulted in extension of the client's intensive care unit (ICU) stay by 3 days because of respiratory problems. The case manager realizes that under the terms of the diagnosis-related group (DRG) payment system for this diagnosis:
a. the cost of caring for this client was $5000 greater than the DRG reimbursement fee, and the hospital will be allowed to collect the additional fees from the insurance company.
b. although the cost of care for this client was greater than the DRG reimbursement amount, the hospital will be reimbursed only at the set fee.
c. the client will be sued to pay back the insurance company for the extra fees incurred because smoking is a modifiable health risk for heart disease.
d. the physician who admitted the client will receive a reduced payment to cover the loss incurred by the hospital.
ANS: B
Correct: Since 1983, if hospital costs exceed the DRG payment for a client's treatment, the hospital incurs a loss, but if costs are less than the DRG amount, the hospital makes a profit. Hospitals face strong financial incentives to reduce the client's length of stay and minimize procedures performed.
Incorrect:
a. The hospital will collect only the amount designated by the DRG and no additional fees will be paid.
c. The hospital is eligible to collect only the maximum amount allowed by the patient's DRG.
d. The physician's charges will not be reduced to cover losses by hospital: the hospital will receive only the maximum amount allowed by this DRG.
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