Distribution of patients into categories reflecting differences in severity of illness or resource consumption. These categories include age, medical diagnosis, severity of illness, or length of stay. A nursing home or hospital’s actual case mix influences cost and scope of the services provided by the facility to the patient, and case mix reimbursement systems adjust payment rates accordingly.
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Case mix index (CMI)
1. Average relative weight of all cases treated at a facility or by a certain physician that reveals the clinical severity of a defined group in relation to other groups in the classification system. Formula: Divide the sum of the weights of diagnosis-related groups (DRGs) for patient discharged during a specified period by the total number of patients discharged. A low CMI may indicate DRG assignments that do not adequately reflect the resources used to treat Medicare patients. 2. In prospective payment systems, this is the comparison of a hospital’s cost for its case mix to the national or regional average hospital cost for a similar case mix.
Case mix index (CMI) formula
Mathematical method used to determine the case mix index by taking the sum of all diagnosis-related groups’ (DRGs’) relative weights and dividing it by the number of Medicare cases.
Case Mix, Health
The number of cases requiring different needs and use of hospital resources.
Case number
1. Numeric assigned by the insurance carrier (payer) to an insurance claim. When appealing a denied or rejected claim, it must appear on each page of the document that is submitted to the payer. 2. See group number.
Case rate
1. In managed health care, an averaging after a flat rate is given to certain categories of procedures. 2. Package price for a specific procedure or diagnostic-related group (DRG). Also called bundled rate or flat fee-per-case .
Case reserve
reserves for outstanding claims built up on a case by case basis with the amount likely to be paid out on each claim being separately estimated.
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Known also as outstanding loss reserves, case reserves are recorded estimates of outstanding unpaid liabilities associated with specific reported claims. Case reserves may pertain to losses, allocated loss adjustment expense (ALAE), or both. Case reserves are established by the cedant if the reinsurer believes a case reserve is inadequate, it may establish an additional amount known as the additional case reserve (ACR).
Case summary card
Form sent by an insurance company’s home office to a branch office that condenses important information about a new case or a change in an existing case. Also known as an abstract.
Case universe
Database of billed insurance claims from which CMRI selects the specific review category samples.
Case-rate capitation
In managed health care, payment to specialists such as orthopedists, urologists, and oncologists based on either referral or episode of care of the patient. Also called contract capitation.