SoonerCare inpatient claims to be reprocessed

Posted on: 4/19/19


The Oklahoma Health Care Authority (OHCA) has made retroactive changes to the rates it pays for inpatient hospital services for SoonerCare (Medicaid) members. As a result, SoonerCare claims for inpatient acute services between Oct. 1, 2018 and April 15, 2019 will be reprocessed over the next six weeks, resulting in both positive and negative adjustments to hospital payments.

SoonerCare pays acute hospitals an amount per inpatient stay that varies according to the diagnosis related group (DRG) assigned to the stay. Annually, OHCA recalculates the relative weights for each DRG based on hospital claim data. In the calculation of DRG weights for services on or after Oct. 1, 2018, four DRGs for neonate services were under-weighted because of an error in DRG assignment logic.  

To correct these underpaid DRG codes, all other DRG weights have been decreased slightly.  

Also, many DRGs are classified by the presence or lack of complications and comorbidities. Some DRGs with low volumes had been weighted to pay more for uncomplicated stays than for those with complications. These DRG weights have also been adjusted.

Information about this correction was included in OHCA Provider Reimbursement Notice 2019-01, along with information on:
  • Medicaid Disproportionate Share Hospital (DSH) audit update;
  • SHOPP recalculations (minor changes to 2018 and 2019 distributions);
  • SHOPP Cost-to-Charge ratio change for Critical Access Hospitals; and
  • Hospital charges. This item is a notice that CMS is requiring OHCA to enforce a federal regulation that prohibits states from paying hospitals more than the hospital’s customary charges. Supplemental payments such as SHOPP are included in this comparison.
Contact Rick Snyder, [email protected], at OHA with questions on these changes.

Save the dates for OHA 2022 events

Posted on: 2/18/22


It’s a new year and a new lineup of important events for you and your staff. Don’t miss out on these opportunities to engage in advocacy, education and networking all year long. Mark your calendar now!

OHA Advocacy Day - Tuesday, April 5, Oklahoma History Center. Join us for our annual legislative day. We will begin with a member briefing at 3 p.m., followed by a legislative reception at 5 p.m. Watch for registration materials soon.

OHA-PAC Golf Tournament - Tuesday, June 21, Jimmie Austin Golf Club at OU, Norman. Time and details TBA.

OHA Health Care Leaders Forum - Tuesday, July 19 - Thursday, July 21, Shangri-La Resort, Grand Lake. Watch for registration soon!

OHA Connect 22 - Wednesday, Nov. 9 - Friday, Nov. 11, Oklahoma City Convention Center and Omni Hotel, downtown Oklahoma City. Plan now to attend OHA’s annual conference and exhibit hall. More details to come.

Details on these events and other upcoming education opportunities will be available on the OHA website.