US · guidance
CMS Pub. 100-04, ch. 3, § 140.2.5.5
Outliers
Section 1886(j)(4) of the Act provides the Secretary with the authority to make payments
in addition to the basic IRF prospective payments for cases incurring extraordinarily high
cost. A case qualifies for outlier payment if the estimated cost of the case exceeds the
adjusted outlier threshold. CMS calculates the adjusted outlier threshold by adding the
IRF PPS payment for the case (that is, the CMG payment adjusted by all of the relevant
facility-level adjustments) and the adjusted threshold amount (also adjusted by all of the
relevant facility-level adjustments). Then, CMS calculates the estimated cost of the case
by multiplying the IRF’s overall cost-to-charge ratio (CCR) by the Medicare allowable
covered charge. If the estimated cost of the case is higher than the adjusted outlier
threshold, CMS makes an outlier payment for the case equal to 80 percent of the
difference between the estimated cost of the case and the outlier threshold.
The adjusted threshold amount and upper threshold CCR are set forth annually in the IRF
PPS notices published in the Federal Register.
History
(Rev. 2673, Issued: 03-14-13, Effective: 04-22-13, Implementation: 04-22-13)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
85ccc20d8afac9dbbbd26289875c7b4f849321d4e01dd0444894cc99a17ccc32
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