How to Figure DRG

Trips to the hospital are often costly and knowing how to calculate your DRG claim can be beneficial.

Diagnosis related group (DRG) classifies hospital patients to determine a fixed payment amount for the services they receive. The DRG amount is based on the patient's principal diagnosis, treatment, age, sex and discharge status. Implemented in 1982, the process for calculating DRG is based on two factors: the negotiated pay rates for the hospital and the amount of resources the patient receives on a visit. Through DRG, you can determine what a claim will be to the insurance provider.

Instructions

1. Locate the hospital's standard base rate (SBR). Find this by contacting the insurance provider or by locating it on the CareFirst BlueCross Blue Shield contract. The SBR rates vary from one facility to the next, based on the size of the hospital and the average charge for specific services. Write down the SBR number that applies to your specific case.

2. Obtain the DRG grouper your case has been assigned. Cases that are similar in resources used are often placed in like DRG groups. You can also find out this number through your insurance provider. Each DRG grouper number is assigned a weight, which is the last piece necessary to calculate DRG.

3. Multiply SBR with the DRG grouper weight to produce the DRG amount. For example, if the SBR is $3,000 and the grouper weight is 0.9, the DRG amount is $2,700.

4. Check for accuracy when you receive your bill. Several scenarios can create discrepancies in the amount calculated and the amount that appears on a statement. The payment amount can be more than the amount billed. The DRG shows the contract amount, regardless of the billed amount.

   Contact your provider for an adjustment if the DRG amount is different because the wrong age was factored in to the calculation.

   Recalculate if your case was placed in the incorrect grouper. Check your diagnosis with the DRG chart you have through your provider. Match up the correct numbers and recalculate.

Tips & Warnings

• Be aware that the DRG amount will likely vary from one hospital to the next, so don't assume that rates for similar or the same procedures performed at different facilities will be the same.

• Most people don't inquire about medical charges when they have insurance, but it's a proactive approach. Don't hesitate to ask questions.

References

• The Free Dictionary: Diagnosis Related Group
• National Center for Biotechnology Information: The Impact of the Diagnosis Related Group