(A) To provide cost containment incentives for providers of care to Medicaid recipients, the department shall convert the Medicaid hospital reimbursement system from a retrospective payment system to a prospective payment system by October 1, 1985. The prospective payment system includes, at a minimum, the following elements:
(1) a maximum allowable payment amount established for individual hospital products, services, patient diagnoses, patient day, patient admission, or per patient, or any combination thereof. This payment must be based on hospital costs rather than hospital charges and must be adjusted at least every two years to reflect the most recent audited cost data available. The department shall set by regulation those circumstances under which a hospital may seek an exception. The maximum allowable payment amount must be weighted to allow for the costs of medical education and primary, secondary, or tertiary care considerations;
(2) payment on a timely basis to the hospital by the commission or patient or both, of the maximum allowable payment amount determined by the commission; and
(3) acceptance by the hospital of the maximum payment amount as payment in full, which includes any deductible or copayment provided for in the state Medicaid program.
(B) The department shall at the same time implement other cost containment measures which include, but are not limited to:
(1) utilization reviews for appropriateness of treatment and length of stay;
(2) preadmission certification of nonemergency admissions;
(3) mandatory outpatient surgery in appropriate cases;
(4) a second surgical opinion pilot study; and
(5) procedures for encouraging the use of outpatient services.
The department, to the fullest extent possible, shall utilize information required in this subsection in the form hospitals are presently submitting the information to other governmental agencies or in the form hospitals are presently utilizing the information within the hospital.
HISTORY: 1985 Act No. 201, Part II, Section 19C; 1989 Act No. 189, Part II, Section 35A; 1993 Act No. 181, Section 1048.
Structure South Carolina Code of Laws
Chapter 6 - Department Of Health And Human Services
Section 44-6-10. Creation of commission; members; term; conflict of interests.
Section 44-6-30. Duties and limitations.
Section 44-6-35. Medicaid waiver protections.
Section 44-6-50. Contracts with other agencies; program monitoring.
Section 44-6-70. Preparation of state plan and resource allocation recommendations.
Section 44-6-80. Annual and interim reports.
Section 44-6-90. Promulgation of regulations; other agencies to cooperate with commission.
Section 44-6-100. Personnel of commission; duties; compensation.
Section 44-6-110. Medicaid providers; boundary clarification.
Section 44-6-115. Covered Medicaid pharmacy services.
Section 44-6-132. Legislative findings and intent.
Section 44-6-135. Short title.
Section 44-6-140. Medicaid hospital prospective payment system; cost containment measures.
Section 44-6-155. Medicaid Expansion Fund.
Section 44-6-160. Target rate of increase for net inpatient charges; excessive increases; penalties.
Section 44-6-200. Falsification of information; penalties.
Section 44-6-220. Notice requirements on nursing home admission applications.
Section 44-6-300. Child development services to be established.
Section 44-6-310. Expansion of existing child development services.
Section 44-6-320. Appropriations.
Section 44-6-400. Definitions.
Section 44-6-420. Enforcement actions; considerations; proportionality to violations.
Section 44-6-470. Fines; use of funds collected.
Section 44-6-530. Federal jurisdiction.
Section 44-6-540. Authority for rulemaking, and to ensure compliance with Medicaid participation.
Section 44-6-610. Citation of article.
Section 44-6-620. Definitions.
Section 44-6-630. Creation of GAPS program; purpose.
Section 44-6-650. Eligibility; benefits.
Section 44-6-660. Evaluation of cost effectiveness; annual report.
Section 44-6-720. Requirements for qualifying for undue hardship waiver.
Section 44-6-725. Promissory notes received by Medicaid applicant or recipient.
Section 44-6-1010. Pharmacy and Therapeutics Committee established; membership.
Section 44-6-1040. Preferred drug list program; procedures to be included.
Section 44-6-1050. Prior authorization for drug; refills; appeals.