COBRA and diagnosis-related group pricing

[t.haley]

Anyone here have any experience with determining COBRA coverage where inpatient hospital stay billed to self-insured plan under diagnosis-related group pricing (DRG)?  Participant's COBRA coverage ended 7/31 and was admitted to the hospital on the same day.  She remained in the hospital until 8/29.  Because charges were billed under DRG (as one claim dated 7/31), former employer's plan being told it is on the hook for the entire bill, even though her COBRA coverage ended 7/31 and 99% of the charges were incurred after COBRA coverage ended.  Thoughts?

[Artie M]

Hmmm... interesting.  I thought DRG claims were considered incurred at discharge.... as that is when the relative-weighted DRG pricing is charged because they take multiple factors that come up after initial diagnosis into account.  However, I can see where an initial DRG could be set upon initial assessment.  Upon admission, they bill the entire DRG amount and then perhaps make an adjustment based on objective factors if necessary (though the adjustment seems to go against the DRG concept).  I think this is done in some forms of Bundled Payments.  This timing does seem like an "end run" around normal timing rules for when a claim is incurred (i.e., when services rendered).  Sorry, this isn't helpful... just replying in hopes someone responds with an authoritative answer.  This should be coming up more often as this pricing has moved out of just Medicare/Medicaid environments.