reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2 - PAYMENT METHODS FOR HOSPITAL SERVICES › Section 296-23A-0230 - How does the department or self-insurer pay out-of-state hospitals for hospital services?

Current through Register Vol. 24-14, July 15, 2024
The department or self-insurer pays out-of-state hospitals
				  for hospital services using a percent of allowed charges (POAC) factor or
				  department fee schedule. The POAC factor may differ for services performed in
				  inpatient and outpatient settings. Payment rates to hospitals located outside
				  of Washington state are calculated by multiplying the out-of-state percent of
				  allowed charges factor (POAC) by the allowed charges.
Amount paid = (out-of-state POAC Factor) X (Allowed
				  Charges).
Out-of-state hospital providers should bill and the
				  department or self-insurer will pay out-of-state hospitals services according
				  to the following table:
Hospital Professional and Ambulance
								Services
Hospital Outpatient
								Services
Hospital Inpatient Services
Professional and ambulance services should be
								billed with CPT and HCPCS codes on current Health Insurance Claim Forms (as
								defined by the National Uniform Claim Committee) under separate provider
								numbers.
These services will be paid using the fee schedule
								rates and payment policies stated in the Washington
Medical Aid Rules
								and Fee Schedules
.
All hospital outpatient services should be billed
								on UB forms under the hospital provider number with revenue codes.
These services will be paid at the out-of-state
								percent of allowed charges (POAC) factor as stated in the Washington
Medical Aid Rules and Fee Schedules
.
All hospital inpatient services should be billed on
								UB forms under the hospital provider number using revenue codes.
These services will be paid at the out-of-state
								percent of allowed charges (POAC) factor as stated in the Washington
Medical Aid Rules and Fee Schedules
.
Military and veteran's administration professional
								and ambulance services should be billed on current Health Insurance Claim Forms
								(as defined by the National Uniform Claim Committee) and will be paid at 100%
								of allowed charges.
Military, veteran's administration, health
								maintenance organization, children's, and state-run psychiatric hospitals will
								be paid at 100% of allowed charges for outpatient hospital services.
Military, veteran's administration, health
								maintenance organization, children's, and state-run psychiatric hospitals will
								be paid at 100% of allowed charges for inpatient hospital services.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.36.080,
					 7.68.030,
					 7.68.080. 07-08-088, §
					 296-23A-0230, filed 4/3/07, effective 5/23/07. Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030,
					 51.36.080. 00-09-078, §
					 296-23A-0230, filed 4/18/00, effective 7/1/00; 97-06-066, § 296-23A-0230,
					 filed 2/28/97, effective 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2 - PAYMENT METHODS FOR HOSPITAL SERVICES › Section 296-23A-0240 - How does the department define and pay a new hospital?

Current through Register Vol. 24-14, July 15, 2024
New hospitals are those open for less than one year prior to
				  the implementation of the department's most recent hospital payment rates. The
				  department will pay new hospitals according to the following table:
Hospital Type or Location
What Diagnosis Related Group (DRG) base
								price applies?
What Per Diem Payment Rates
								Apply?
What percent of allowed charges (POAC)
								factor applies?
Military, Veterans Administration, State
								Psychiatric, Health Maintenance Organization, Children's,
Exempt
Exempt
Paid 100% of allowed charges
Chronic Pain Management Program
Exempt, paid per department agreement
Exempt, paid per department agreement
Exempt, Paid per department agreement
Other Washington Hospital
Weighted median case-mix adjusted average cost per
								case for Washington DRG hospitals, except major teaching hospitals
Washington statewide average per diem rates
Washington statewide average POAC
A new hospital will be paid using its hospital-specific POAC
				  within three years of receiving a provider account number(s) from the
				  department.
Statutory Authority:
					 RCW
					 51.04.030 and 51.12.330. 06-12-073, §
					 296-23A-0240, filed 6/6/06, effective 7/7/06. Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030,
					 51.36.080. 00-06-027, §
					 296-23A-0240, filed 2/24/00, effective 3/26/00; 97-06-066, § 296-23A-0240,
					 filed 2/28/97, effective 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2 - PAYMENT METHODS FOR HOSPITAL SERVICES › Section 296-23A-0250 - Does a change in hospital ownership affect a hospital's payment rate?

Current through Register Vol. 24-14, July 15, 2024
A change in ownership does not constitute the creation of a
				  new hospital. If a hospital changes ownership, rates will remain the same as
				  those payable to the previous owner.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0250, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.1 - PERCENT OF ALLOWED CHARGES (POAC) PAYMENT METHODS AND POLICIES › Section 296-23A-0300 - When do percent of allowed charges (POAC) payment factors apply?

Current through Register Vol. 24-14, July 15, 2024
The department may designate from time to time, those
				  hospitals and hospital services to be paid using POAC
				  factors.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0300, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.1 - PERCENT OF ALLOWED CHARGES (POAC) PAYMENT METHODS AND POLICIES › Section 296-23A-0310 - What is the method for calculating percent of allowed charges (POAC) factors?

Current through Register Vol. 24-14, July 15, 2024
POAC factors are based on medicare cost report data and are
				  calculated by dividing adjusted operating expenses by adjusted patient
				  revenues. The department will allow costs for graduate medical education and
				  charity care. Allowable costs for charity care shall not exceed a maximum of
				  two percent of the facility's total allowable costs. A hospital's POAC factor
				  shall not exceed one hundred percent of allowed charges.
Payment rates are calculated by multiplying the POAC factor
				  by the allowed charges.
Amount Paid = (POAC Factor) X (Allowed
				  Charges)
Each hospital will be notified of their revised POAC factor
				  thirty days prior to implementation. Incorrect data or erroneous calculations
				  can be appealed in accordance with WAC
				  296-23A-0600.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0310, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.2 - PER DIEM PAYMENT METHODS AND POLICIES › Section 296-23A-0350 - When do per diem rates apply?

Current through Register Vol. 24-14, July 15, 2024
The department may designate from time to time, those
				  hospitals and hospital services paid on a per diem basis. For example, the
				  department may develop per diem rates for the following diagnosis-related-group
				  (DRG) categories:
Psychiatric;
Rehabilitation;
Substance abuse;
Medical;
Surgical; and
Other categories as determined by the
								department.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0350, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.2 - PER DIEM PAYMENT METHODS AND POLICIES › Section 296-23A-0360 - What is the method for calculating per diem rates?

Current through Register Vol. 24-14, July 15, 2024
Per diem rates are calculated by dividing the total costs for
				  all relevant cases in the historical data base by the total number of days. The
				  total number of days is equal to the sum of the number of days for each
				  relevant case. The number of days per case is equal to last date of service
				  minus the first date of service. The department will allocate costs at the
				  detailed revenue code level using medicare cost report data and medicare
				  definitions for allowable costs. The department will allow costs for graduate
				  medical education and charity care. Allowable costs for charity care shall not
				  exceed a maximum of two percent of the facility's total allowable costs.
Payment rates are equal to the applicable per diem rate
				  multiplied by the number of days allowed by the department. The department does
				  not pay for the day of discharge. Payment shall not exceed allowed billed
				  charges.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0360, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0400 - What is a "diagnosis-related-group" payment system?

Current through Register Vol. 24-14, July 15, 2024
A diagnosis-related-group (DRG) system categorizes patients
				  into clinically coherent and homogenous groups with respect to resource use.
				  The department will use an all-patient grouper to perform the diagnostic
				  categorization. To the extent feasible, where DRG relative weights meet
				  acceptable reliability and validity standards, the department will use DRG per
				  case rates for payment of hospital inpatient services.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0400, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0410 - How does the department calculate diagnosis-related-group (DRG) relative weights?

Current through Register Vol. 24-14, July 15, 2024
In calculating DRG relative weights, the department
				  will:
(1) Allocate costs for hospital
				services at a detailed revenue code level using medicare cost report data and
				medicare definitions for allowable costs. The department will allow costs for
				graduate medical education and charity care. Allowable costs for charity care
				shall not exceed a maximum of two percent of the facility's total allowable
				costs.
(2) Classify department
				hospital admissions data and hospital discharge data in the Washington state
				department of health's comprehensive hospital abstract reporting system
				(CHARS), using an all-patient grouper.
(3) Establish relative weights from
				department of labor and industries' hospital admission data. If the
				department's data is not sufficient to calculate stable relative weights, the
				department may use hospital discharge data in the Washington state department
				of health's comprehensive hospital abstract reporting system (CHARS) or another
				appropriate data source.
(4)
				Exclude the following types of cases from DRG relative weight calculations:
				Transfers, statistical outliers, length of stay equal to zero, psychiatric,
				substance abuse and rehabilitation DRGs, out-of-state hospitals, other
				hospitals and services designated as exempt from DRG payment rates.
See WAC
				  296-23A-0470 and
				  296-23A-0480 for exclusions and
				  exceptions to DRG payments for hospital services.
(5) Test each DRG statistically for adequacy
				of sample size to ensure that relative weights meet acceptable reliability and
				validity standards.
(6) Replace
				unstable department relative weights with stable CHARS derived relative
				weights.
(7) Standardize department
				and CHARS relative weights to a statewide case-mix index of 1.0.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0410, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0420 - How does the department determine the base price for hospital services paid using per case rates?

Current through Register Vol. 24-14, July 15, 2024
The department determines the base price for hospital
				  services paid using per case rates according to the following table:
Type of Hospital
Base Price
Major Teaching
								Hospital
:
Harborview Medical Center or
University of Washington
Hospital-specific case-mix adjusted average cost
								per case
Other DRG Hospital
Weighted median case-mix adjusted average cost per
								case for DRG hospitals, except major teaching hospitals
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0420, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0430 - How does the department calculate a hospital specific case-mix adjusted average cost per case?

Current through Register Vol. 24-14, July 15, 2024
The department determines the case-mix adjusted average cost
				  per case for each hospital by:
(1)
				Allocating costs for hospital services at a detailed revenue code level using
				medicare cost report data and medicare definitions for allowable costs. The
				department will allow costs for graduate medical education and charity care.
				Allowable costs for charity care shall not exceed a maximum of two percent of
				the facility's total allowable costs;
(2) Totaling the costs of all DRG
				cases;
(3) Dividing the total by
				the number of cases; and
(4) Then
				dividing that number by the hospital's case-mix index.
(5) Per case costs are indexed to the payment
				period for inflation and other factors.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0430, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0440 - How does the department calculate the base price for DRG hospitals, except major teaching hospitals?

Current through Register Vol. 24-14, July 15, 2024
The department calculates the base price for DRG hospitals,
				  except major teaching hospitals by:
(1) Calculating each hospital's case-mix
				adjusted average cost per case;
(2)
				Weighting each hospital's case-mix adjusted average cost per case by the number
				of cases at that hospital;
(3)
				Determining the median (fiftieth percentile) of the list of case-mix adjusted
				average costs per case.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0440, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0450 - What cases does the department exclude from base price calculations?

Current through Register Vol. 24-14, July 15, 2024
The department excludes the following types of cases from
				  base price calculations:
Transfers;
Statistical outliers;
Length of stay equal to zero;
Psychiatric, substance abuse and rehabilitation
								DRGs;
Out-of-state hospitals; and
Other hospitals and services designated as exempt
								from DRG payment rates.
See WAC
				  296-23A-0470 and
				  296-23A-0480 for exclusions and
				  exceptions to DRG payments for hospital services.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0450, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0460 - How does the department calculate the diagnosis-related-group (DRG) per case payment rate for a particular hospital?

Current through Register Vol. 24-14, July 15, 2024
The DRG per case rate for a particular hospital is calculated
				  by multiplying the assigned DRG relative weight for that admission by the
				  applicable base price.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0460, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0470 - Which exclusions and exceptions apply to diagnosis-related-group (DRG) payments for hospital services?

Current through Register Vol. 24-14, July 15, 2024
The following exclusions and exceptions apply to DRG payments
				  for hospital services:
Psychiatric, rehabilitation, and chemical
								dependency (substance abuse) services will be excluded from payment by DRG
								rates. These services will be paid using per diem payment rates.
Ambulance and air transportation services are
								excluded from DRG payments.
Bills assigned to a DRG that is defined as
								ungroupable will be denied.
Bills where the principal diagnosis is invalid as a
								discharge diagnosis will be denied.
Bills where the injured worker has been admitted
								and discharged in less than twenty-four hours will be reviewed by the
								department and may be paid as hospital outpatient services.
The department may choose to exclude other DRGs
								from DRG payment rates due to concerns about access, case volume or other
								considerations. These services will be paid using the applicable percent of
								allowed charges (POAC) factor and per diem rates.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0470, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0480 - Which hospitals does the department exclude from diagnosis-related-group (DRG) payments?

Current through Register Vol. 24-14, July 15, 2024
The following hospitals are excluded from DRG
				  payments:
Military, Veterans Administration, state
								psychiatric facilities, health maintenance organizations (HMO), and children's
								hospitals will be paid their allowed charges.
Department-approved chronic pain management
								programs will be paid according to department agreement or contract.
Hospitals located outside of Washington will be
								paid a percent of allowed charges (POAC).
Other hospitals, as determined by the department,
								may be excluded from DRG reimbursement rates due to concerns about access, case
								volume or other considerations. These facilities will be paid using the
								applicable POAC factor and per diem rates.
Statutory Authority:
					 RCW
					 51.04.030 and 51.12.330. 06-12-073, §
					 296-23A-0480, filed 6/6/06, effective 7/7/06. Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0480, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0490 - Which hospital services does the department include in diagnosis-related-group (DRG) rates?

Current through Register Vol. 24-14, July 15, 2024
Unless otherwise specified, the department will include in
				  the DRG rate all hospital services provided to an injured worker admitted to a
				  hospital. Hospital services must be medically necessary for the treatment of
				  the accepted occupational disease or injury.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0490, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0500 - When does a case qualify for high outlier status?

Current through Register Vol. 24-14, July 15, 2024
Outlier payments apply only to diagnosis-related-group (DRG)
				  reimbursed cases with unusually high or low costs. Outlier status does not
				  apply to cases paid using a percent of allowed charges (POAC) factor or per
				  diem rates.
A case is considered a high cost outlier if the costs for the
				  case exceed the outlier threshold for the assigned diagnosis-related-group. The
				  costs for a case are determined by multiplying the allowed charges for the case
				  by the hospital specific POAC factor. The threshold used to define a high
				  outlier case is the greater of a dollar threshold of twelve thousand dollars or
				  two standard deviations above the statewide average cost for each DRG paid by
				  the department.
The dollar threshold may be adjusted annually for inflation
				  or other factors as determined by the department. The standard deviations for
				  DRGs will be computed from all relevant cases in the historical data base,
				  excluding statistical outliers.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030. 00-24-066, §
					 296-23A-0500, filed 12/1/00, effective 1/1/01. Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0500, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0520 - How does the department pay for high outlier cases?

Current through Register Vol. 24-14, July 15, 2024
Cases defined as high cost outliers will be reimbursed at the
				  diagnosis-related-group (DRG) payment rate plus one hundred percent of costs in
				  excess of the threshold. Costs are determined by multiplying the allowed
				  charges by the hospital specific percent of allowed charges (POAC)
				  factor.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0520, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0530 - How does a case qualify for low outlier status?

Current through Register Vol. 24-14, July 15, 2024
To qualify as a low outlier, the allowed charges multiplied
				  by that hospital's percent of allowed charges (POAC) factor must be less than
				  ten percent of the statewide diagnosis-related-group (DRG) rate or five hundred
				  dollars whichever is greater. The standard deviations for DRGs will be computed
				  from all relevant cases in the historical data base, excluding statistical
				  outliers.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0530, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0540 - How does the department pay for low outlier cases?

Current through Register Vol. 24-14, July 15, 2024
Low outlier cases are paid by multiplying each hospital's
				  specific percent of allowed charges (POAC) factor by the allowed charges for
				  the case.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0540, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0550 - Under what circumstances will the department pay for interim bills?

Current through Register Vol. 24-14, July 15, 2024
The department will deny interim bills which are assigned to
				  diagnosis-related-groups (DRGs) paid per case rates by the department.
If an interim bill is coded as a diagnosis-related-group
				  (DRG) not paid per case rates by the department, then the bill will be paid
				  using the applicable percent of allowed charges (POAC) factor and per diem
				  rates. If a subsequent bill coded as a DRG paid per case rates by the
				  department, for the same injured worker, has a first date of service within
				  seven days of the last date of service of the previous bill, then the bills
				  will be subject to review and adjustment by the department.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0550, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0560 - How does the department define and pay for hospital readmissions?

Current through Register Vol. 24-14, July 15, 2024
The department will review hospital readmissions occurring
				  within seven days of discharge and will determine whether the second admission
				  resulted from premature discharge. Payment for services associated with
				  readmission will depend upon the review. For example:
If the second admission is determined unnecessary,
								reimbursement may be denied.
If the admission was avoidable, the two admissions
								may be combined and a single diagnosis-related-group (DRG) payment made.
If two different DRG assignments are involved,
								reimbursement for the appropriate DRG will be based upon review of the
								case.
Readmissions involving different hospitals will be
								reviewed by the department and may be paid using the payment method for
								transfers.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0560, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0570 - How does the department define a transfer case?

Current through Register Vol. 24-14, July 15, 2024
A transfer case is defined as an injured worker's admission
				  to another acute care hospital within seven days of that worker's previous
				  discharge. All bills for transfer cases will be subject to review by the
				  department and payment will be determined based on that analysis. The
				  transferring hospital may qualify for high and low outlier
				  status.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0570, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0575 - How does the department pay a transferring hospital for a transfer case?

Current through Register Vol. 24-14, July 15, 2024
When the stay at the transferring hospital is a
				  diagnosis-related-group (DRG) paid by the department, and does not qualify as a
				  low outlier, the transferring hospital is paid a graduated per diem rate for
				  each day of care allowed by the department. If the case qualifies as a low cost
				  outlier, the hospital will be paid the graduated per diem amount or low cost
				  outlier payment amount, whichever is lower. The per diem rate is determined by
				  dividing that hospital's rate for the appropriate DRG by that DRG's average
				  length of stay as determined by the department. Payment for the first day of
				  service will be two times the per diem rate. For subsequent allowed days, the
				  basic per diem rate will be paid up to the full DRG payment amount. Unless the
				  case qualifies as a high outlier, payment to the transferring hospital will not
				  exceed the appropriate DRG rate that would have been paid had the injured
				  worker not been transferred to another hospital.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0575, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES › Section 296-23A-0580 - How does the department pay the receiving hospital for a transfer case?

Current through Register Vol. 24-14, July 15, 2024
The hospital receiving a transfer will be paid according to
				  the department's review of the case. If the receiving hospital's stay is a
				  diagnosis-related-group (DRG) paid by the department, then the hospital will
				  receive the appropriate per case and outlier payments. If the case is not a DRG
				  paid by the department, then the hospital is paid using applicable percent of
				  allowed charges (POAC) factor or per diem rates.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0580, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 3 - REQUESTING A HOSPITAL RATE ADJUSTMENT › Section 296-23A-0600 - How can a hospital request a rate adjustment?

Current through Register Vol. 24-14, July 15, 2024
Hospitals may submit a request for adjustment to their rate
				  if:
The rate methodology or principles of reimbursement
								established in department publications were incorrectly applied, or
Incorrect data or erroneous calculations were used
								in the establishment of the hospital's rate.
In all circumstances, requests for adjustments to rates must
				  show how the rate adjustment was calculated and contain sufficient detail to
				  permit an audit. Requests must specify the nature and the amount of the
				  adjustment sought. The burden of proof is on the requesting
				  hospital.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0600, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 3 - REQUESTING A HOSPITAL RATE ADJUSTMENT › Section 296-23A-0610 - Where must hospitals submit requests for rate adjustments?

Current through Register Vol. 24-14, July 15, 2024
Hospitals must submit requests for rate adjustments in
				  writing to:
Department of Labor and Industries
Health Services Analysis
Request for Hospital Rate Adjustment
P.O. Box 44322
Olympia, Washington 98504-4322.
Requests must be received within sixty days after the
				  facility receives notice of its payment rates.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0610, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 3 - REQUESTING A HOSPITAL RATE ADJUSTMENT › Section 296-23A-0620 - What action will the department take upon receipt of a request for a rate adjustment?

Current through Register Vol. 24-14, July 15, 2024
Upon receipt of the request, the department shall determine
				  the need for a conference with the hospital and will contact the facility to
				  arrange a conference if needed. The conference, if needed, must be held within
				  sixty days of the department's receipt of the request.
Within thirty calendar days of the receipt of the request for
				  review or the date of the conference, the department shall notify the facility
				  of the action to be taken by the department.
If the department's review of the material submitted by the
				  hospital results in a favorable determination for the hospital, the department
				  will modify the hospital's payment rate(s). The revised rate(s) will apply to
				  all bills with a date of admission on or after a date chosen by the department.
				  The chosen date will be within one hundred twenty days of the department's and
				  hospital's agreement to modify the rate(s).
If the department's review of the material submitted by the
				  hospital results in an unfavorable determination for the hospital, the hospital
				  may file an appeal with the board of industrial insurance
				  appeals.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030 and
					 51.36.080. 97-06-066, §
					 296-23A-0620, filed 2/28/97, effective
					 4/1/97.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 4 - AMBULATORY PAYMENT CLASSIFICATION PAYMENT METHODS AND POLICIES › Section 296-23A-0700 - What is the "ambulatory payment classification" (APC) payment system?

Current through Register Vol. 24-14, July 15, 2024
The APC outpatient prospective payment system (OPPS) is a
				  reimbursement method that categorizes outpatient visits into groups according
				  to the clinical characteristics, the typical resource use, and the costs
				  associated with the diagnoses and the procedures performed. The groups are
				  called Ambulatory Payment Classifications (APCs). Unless otherwise stated in
				  departmental payment policies, the department follows billing policies used by
				  the Centers for Medicare and Medicaid Services (CMS) for the hospital
				  outpatient prospective payment system to pay some hospitals for covered
				  outpatient services provided to injured workers. The department will utilize
				  CMS' current outpatient code editor to categorize outpatient visits.
The payment system methodology uses CMS' outpatient
				  prospective payment system's relative weight factor for each APC group and a
				  blend of statewide and hospital-specific rates for each APC.
For a complete description of CMS' Prospective Payment System
				  for Hospital Outpatient Department Services see 42 C.F.R., Chapter IV, Part
				  419, et al.
Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030,
					 51.36.080,
					 51.36.085. 01-24-045, §
					 296-23A-0700, filed 11/29/01, effective
					 1/1/02.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 4 - AMBULATORY PAYMENT CLASSIFICATION PAYMENT METHODS AND POLICIES › Section 296-23A-0720 - How does the department calculate the hospital-specific per APC rate used for paying outpatient services under the outpatient prospective payment system (OPPS)?

Current through Register Vol. 24-14, July 15, 2024
(1) OPPS payment
				rates are calculated with a formula that blends a hospital-specific rate and a
				statewide rate. Each hospital's historic labor and industries' reimbursement
				level in combination with the department's statewide payments will determine
				payment rates.
(2) For the
				statewide rate, the department:
(a)
				Determines the total number of APC procedures that the department paid the
				covered hospitals. The relative weights for all of these APCs are
				summed.
(b) Determines the total
				dollar amount the department paid for those APCs.
(c) Determines the total dollar amount the
				department paid as outlier payments.
(d) Subtracts the total outlier payments in
				(c) of this subsection from the total dollar amount in (b) of this subsection
				and then divides the adjusted dollar amount by the APC relative weight total
				from (a) of this subsection.
(Sum of APC payments - Sum of outlier payments)/Sum of APC
				  relative weights = Statewide rate
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 4 - AMBULATORY PAYMENT CLASSIFICATION PAYMENT METHODS AND POLICIES › Section 296-23A-0730 - How does the department determine the APC relative weights?

Current through Register Vol. 24-14, July 15, 2024
The relative weight for each APC is the current relative
				  weight listed by CMS for the corresponding APC.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030,
					 51.36.080,
					 51.36.085. 01-24-045, §
					 296-23A-0730, filed 11/29/01, effective
					 1/1/02.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 4 - AMBULATORY PAYMENT CLASSIFICATION PAYMENT METHODS AND POLICIES › Section 296-23A-0740 - How does the department calculate payments for covered outpatient services through the outpatient prospective payment system (OPPS)?

Current through Register Vol. 24-14, July 15, 2024
(1) Billed services that are reimbursed by
				the OPPS are grouped into one or more APCs using the outpatient code editor
				software.
(2) Additional payment
				may be made for services classified by CMS as transitional
				pass-through.
(3) Incidental
				services are grouped within an APC and are not paid separately.
(4) The OPPS APC payment method uses an APC
				relative weight for each classification group (APC) and the current
				hospital-specific blended rate to determine the APC payment for an individual
				service.
(5) For each additional
				APC listed on a single claim for services, the payment is calculated with the
				same formula and then discounted. L&I follows all discounting policies used
				by CMS for the Medicare Prospective Payment System for Hospital Outpatient
				Department Services.
(6) APC
				payment for each APC = (APC relative weight x hospital-specific blended rate)*
				discount factor (if applicable) x units (if applicable).
(7) The total payment on an APC claim is
				determined mathematically as follows:
(a) Sum
				of APC payments for each APC +
(b)
				Additional payment for each transitional pass-through (if applicable)
				+
(c) Additional outlier payment
				(if applicable).
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 4 - AMBULATORY PAYMENT CLASSIFICATION PAYMENT METHODS AND POLICIES › Section 296-23A-0750 - What exclusions and exceptions apply to ambulatory-payment-classification (APC) payments for hospital services?

Current through Register Vol. 24-14, July 15, 2024
(1) Critical access hospitals as identified
				by the Washington state department of health (DOH).
(2) All out-of-state hospitals.
(3) Military/veterans hospitals.
(4) Psychiatric hospitals.
(5) Rehabilitation hospitals.
(6) Cancer hospitals.
(7) Children's hospitals.
(8) Ambulatory surgery centers.
(9) Any outpatient service or special program
				identified by the department or by CMS as being a non-APC service.
(10) Any inpatient-only procedures as
				identified by CMS.
(11) Any APCs
				identified by the department as a non-APC service.
Statutory Authority:
					 RCW
					 51.04.030 and 51.12.330. 06-12-073, §
					 296-23A-0750, filed 6/6/06, effective 7/7/06. Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030,
					 51.36.080,
					 51.36.085. 01-24-045, §
					 296-23A-0750, filed 11/29/01, effective
					 1/1/02.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 4 - AMBULATORY PAYMENT CLASSIFICATION PAYMENT METHODS AND POLICIES › Section 296-23A-0770 - How will excluded outpatient services and hospitals be paid?

Current through Register Vol. 24-14, July 15, 2024
Services excluded from APC-payment, if deemed appropriate for
				  reimbursement, will be reimbursed using an alternate outpatient payment method,
				  such as a specific fee schedule and/or using the hospital-specific or the
				  statewide average percent of allowed charges (POAC).
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030,
					 51.36.080,
					 51.36.085. 01-24-045, §
					 296-23A-0770, filed 11/29/01, effective
					 1/1/02.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 4 - AMBULATORY PAYMENT CLASSIFICATION PAYMENT METHODS AND POLICIES › Section 296-23A-0780 - What information needs to be submitted for the hospital to be paid for outpatient services?

Current through Register Vol. 24-14, July 15, 2024
Each claim for services must include the required elements as
				  described within the current L&I hospital billing and administrative
				  guidelines.
Note:
Includes Provider General Billing Manual; Billing
								Instructions for Hospital Services; Provider Bulletins; and Provider
								Updates.
Statutory Authority:
					 RCW
					 51.04.020,
					 51.04.030,
					 51.36.080,
					 51.36.085. 01-24-045, §
					 296-23A-0780, filed 11/29/01, effective
					 1/1/02.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23B - Ambulatory surgery center payment › Section 296-23B-0100 - Who may bill for ambulatory surgery center services?

Current through Register Vol. 24-14, July 15, 2024
Only facilities that meet the criteria below may bill for
				ambulatory surgery center (ASC) services.
An ambulatory surgery center is an outpatient facility where
				surgical services are provided and that meets the following three
				requirements:
(1) Must be licensed by
			 the state(s) in which it operates, unless that state does not require
			 licensure.
(2) Must have at least
			 one of the following credentials:
(a)
			 Medicare certification as an ambulatory surgery center; or
(b) Accreditation as an ambulatory surgery
			 center by a nationally recognized agency acknowledged by the Centers for
			 Medicare and Medicaid Services (CMS).
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23B - Ambulatory surgery center payment › Section 296-23B-0110 - How does an ambulatory surgery center bill for services?

Current through Register Vol. 24-14, July 15, 2024
Ambulatory surgery centers must submit bills for services on a
				national standard form specified by the department of labor and industries.
				Bills also may be submitted electronically using department file format
				specifications. Providers must follow the instructions in the
General
				Provider Billing Manual
and
Billing Instructions
.
				Special billing policies for ambulatory surgery centers are in the
Medical Aid Rules and Fee Schedules
under
Ambulatory
				Surgery Center Payment Policies
.
Note: Copies of billing manuals, billing instructions and the
				Medical Aid Rules and Fee Schedules may be obtained from Department of Labor
				and Industries, Warehouse, P.O. Box 44843, Olympia, WA 98504-4843 or
				360-902-5754. The Medical Aid Rules and Fee Schedules may also be viewed online
				at
www.lni.wa.gov
.
Statutory Authority:
				  RCW
				  51.36.080,
				  51.04.030,
				  51.36.010,
				  51.04.020. 01-21-140, §
				  296-23B-0110, filed 10/24/01, effective
				  1/1/02.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23B - Ambulatory surgery center payment › Section 296-23B-0120 - What procedures are covered in an ambulatory surgery center?

Current through Register Vol. 24-14, July 15, 2024
The department will use the Centers for Medicare and Medicaid
				Services (CMS) list of procedures covered in an ambulatory surgery center plus
				additional procedures as determined by the department. All procedures covered
				in an ambulatory surgery center are listed in the
Medical Aid Rules and
				Fee Schedules, Ambulatory Surgery Center Payment Policies
section.
				Certain procedures are still subject to the utilization review program.
				Procedures that are not listed are not covered in an ambulatory surgery
				center.
Under certain conditions, the director, the director's
				designee, or self-insurer, in their sole discretion, may determine that a
				procedure not on the list may be authorized in an ambulatory surgery center.
				For example, if the procedure could be harmful to a particular patient unless
				performed in an ambulatory surgery center. Requests for coverage under these
				special circumstances require prior authorization. The process for requesting
				coverage is outlined in the
Medical Aid Rules and Fee Schedules,
				Ambulatory Surgery Center Payment Policies
section.
The department will allow some procedures to be covered in an
				outpatient setting that CMS covers only in an inpatient setting. The department
				will cover these procedures in an ambulatory surgery center if the following
				criteria are met:
(1) The surgeon
			 deems that it is safe and appropriate to perform such a procedure in an
			 outpatient setting; and
(2) The
			 procedure meets the department's utilization review requirements.
Notes: For information on the utilization review program please
				see the following: WAC
				296-20-024 for utilization
				management authority. WAC
				296-20-01002 for definition of
				utilization review. WAC
				296-20-02700 through
				296-20-03002 for medical coverage
				policies. Provider bulletins describing the utilization review program. These
				may be viewed online at
www.lni.wa.gov
.
Statutory Authority:
				  RCW
				  51.36.080,
				  51.04.030,
				  51.36.010,
				  51.04.020. 01-21-140, §
				  296-23B-0120, filed 10/24/01, effective
				  1/1/02.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23B - Ambulatory surgery center payment › Section 296-23B-0130 - What payment can an ambulatory surgery center expect for providing services?

Current through Register Vol. 24-14, July 15, 2024
The department pays the lesser of the billed charge (the ASC's
				usual and customary fee) or the fee schedule's maximum allowed rate. The fee
				schedule for ambulatory surgery centers is in the
Medical Aid Rules and
				Fee Schedules
.
Statutory Authority:
				  RCW
				  51.36.080,
				  51.04.030,
				  51.36.010,
				  51.04.020. 01-21-140, §
				  296-23B-0130, filed 10/24/01, effective
				  1/1/02.
Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23B - Ambulatory surgery center payment › Section 296-23B-0140 - When will the rates and policies for ambulatory surgery centers be updated?

Current through Register Vol. 24-14, July 15, 2024
The fee schedule, codes, and policies for ambulatory surgery
				centers will be reviewed periodically. The department will publish provider
				bulletins to clarify, update, and inform ambulatory surgery centers about
				changes in policies or fees. They also will be published each July in the
Medical Aid Rules and Fee Schedules
.
Statutory Authority:
				  RCW
				  51.36.080,
				  51.04.030,
				  51.36.010,
				  51.04.020. 01-21-140, §
				  296-23B-0140, filed 10/24/01, effective
				  1/1/02.