Institutional Rate Setting and Support

Institutional Rate Setting Services and Support Services

Institutional services, such as inpatient and outpatient hospital, skilled nursing facility, and nursing facility services are a significant spend and driver of healthcare costs. Medicaid and other state agencies need, and should adopt, payment methodologies that are fair, promote efficiency, focus on quality, and ensure access. PCG has served as a trusted advisor to payers to transform their institutional reimbursement methods.

Our experience includes:

  • Transitioning from antiquated reimbursement models to acuity-based payment systems, including AP-DRGs, APR-DRGs, MS-DRGs, RUGs, APCs, and EAPGs;
  • Developing and/or recalibrating weights associated with acuity-based payment systems;
  • Establishing provider-specific, class-specific, and like-provider base rates;
  • Determining base rate add-ons for Disproportionate Share Hospitals (DSH), rural, and academic medical institutions;
  • Conducting financial modeling to understand fiscal impacts that result from new reimbursement methods, with a specific focus on the safety net system of care;
  • Conducting trainings to the provider community and provider associations on the facets of reimbursement models; and
  • Guiding and assisting payers with necessary system changes, as well as updating provider reimbursement models.

In addition to calculating institutional payment rates, our team of experts has assisted Medicaid agencies and other payers with related institutional reimbursement issues. 

We can assist your agency with:

  • Upper payment limit calculations and demonstrations;
  • Development of Medicaid state plan amendments articulating new reimbursement methods;
  • Determining DSH payment calculations and distribution models;
  • Streamlining financial reporting processes through our proprietary web-based cost reporting systems; and
  • Developing provider assessment models, including all statistical tests, to support new supplemental payment models.


Contact us today to learn more about our institutional rate setting services and how we may be able to serve you.