In medical billing, inliers refer to a case where the charge for treatment lies within the established cost limits of the diagnosis-related group (DRG). It is used to determine if the inpatient hospital claim satisfies the criteria for the cost outlier payment (Jentzsch et al., 2018). An example of an inlier in hospital billing is the Weighted Inlier Equivalent Separation (WIES) process that is used in determining the ratio of price subsidy applied to eligible patients. Outlier refers to a payment that is made to prevent healthcare institutions from the notable financial crisis that comes as a result of patient-care cases that may be expensive to undertake (Jentzsch et al., 2018). An example of an outlier is Medicare policy, which has segments that protect US-based hospitals from incurring high costs from extraordinary operations. Comorbidity refers to a case when a patient has two or more illnesses at the same time. The term is used to express the context of case-mix reimbursement in hospitalization (Jentzsch et al., 2018). Example of comorbidity is hypertension, cardiovascular disease, and diabetes issues during hospitalization.
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Inliers, outliers, and comorbidity have a potential effect on hospital billing. First, during the inlier determination process, the person responsible for reimbursement may severely adjust an oft-cited requirement when comparing the medical delivery system (Kümpel & Schneider, 2020). Medicare hospital outlier payments may lead to increased scrutiny that may make healthcare institutions be held accountable on the monetary issues, mostly reimbursement. Comorbidities, on the other hand, may lead to prolonged recovery time, which means hospitals will be at risk of high costs while treating patients.
Among the three terms, outliers have the most impact than inliers and comorbidities. The reason is that during the process of outlier calculation, healthcare institutions produce many documents and records that reveal all the financial dealings. Thus, hospital personnel that may have unclear financial dealings will be exposed (Kümpel & Schneider, 2020). Upon disclosure of a violation of financial rules in hospitals, the healthcare institutions will be saved from losing money to greedy individuals. Hence it prevents possible occasions of financial crisis.
Jentzsch, T., Seifert, B., Neuhaus, V., & Moos, R. M. (2018). Predictors for shorter and longer length of hospital stay outliers: a retrospective case-control study of 8247 patients at a university hospital trauma department. Swiss medical weekly, 148, 16-19.
Kümpel, C., & Schneider, U. (2020). Additional reimbursement for outpatient physicians treating nursing home residents reduces avoidable hospital admissions: Results of a reimbursement change in Germany. Health Policy, 124(4), 470-477. Web.