Pediatric Resource Group (PRG)’s Post

Payments for pediatric hospitalizations oftentimes don't cover the cost of care. Over 50% of pediatric discharges in the country are paid by state Medicaid programs. For some children's hospitals, it could be 75% or more. For the same diagnosis, Medicaid pays 20%-50% less than Medicare rates and orders of magnitude less than commercial (PPO) payers. The map below shows your state's Medicaid payment model. If you have any percentage of peds/NICU discharges that are paid by the DRG method (some commercial payers pay by DRG as well), you need to ensure your Clinical Documentation Integrity (CDI) team is reviewing those cases. Given the chronic underpayment for pediatrics, hospitals should be using their CDI teams to optimize severity-adjustment, CMI, and hospital reimbursement for this patient population. Pediatric Resource Group (PRG) is the only pediatric focused CDI consulting firm in the country. Our team has assessed, developed, optimized, or leads dozens of CDI programs at academic medical centers and community hospitals. Let us help you improve the financial health of your peds/NICU cases so you can expand the care provided to the neonates and children in your community.

  • No alternative text description for this image
Michelle M. Wieczorek RN RHIT CPHQ CCDS-O

Expert in CDI, HIM, risk adjustment and value based care. Facilitating adoption of AI technology as a strategist/operator. Member of 2024-2025 ACDIS Leadership Council. Making good CDI Programs great!

5mo

I would also argue that in states covered by ACA plans, risk adjusting your pediatric population is also an important consideration for a CDI program. Commercial plans taking on this risk may be willing to pay for resources to assure that their members are risk adjusted when they encounter acute or post acute care. Exciting times for pediatric CDI.

To view or add a comment, sign in

Explore topics