West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-05 - Hospital Cost-Based Rate Review System › Section 65-5-3 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
As used in this rule, all terms have the same meaning as
				  provided in the definition section of the Health Care Cost Review Authority
				  Act, W. Va. Code '16-29B-3.
				  Definitions of additional terms are set forth below and whenever those terms
				  are used, the following definitions apply, except where the context may
				  expressly otherwise require.
3.1.
				"Act" means the West Virginia Health Care Cost Review Authority Act, W. Va.
				Code '16-29B-1
				et.seq.
3.2. "Adjusted days" means
				the total acute care inpatient days plus an amount of equivalent outpatient
				days. The total adjusted days is computed as follows:
Where:
A = Acute Care Routine Inpatient Revenue
B = Acute Care Ancillary Inpatient Revenue
C = Acute Care Inpatient Days
D = Average Acute Care Inpatient Revenue per Day
E = Outpatient Revenue
F = Equivalent Outpatient Days
3.3. "Affected party" means any interested
				party which is recognized by the Authority as an affected party.
3.4. "Authority" means the West Virginia
				Health Care Cost Review Authority.
3.5. "Case Mix Index" means an index
				determined by multiplying the respective DRG weights in effect at the time of
				the discharges by the number of discharges for each DRG weight classification
				in order to arrive at a weighted DRG for each DRG classification, which DRG
				classifications are then added together and divided by the total number of
				discharges for the hospital to arrive at a case mix index for the respective
				category of payors, all as determined by the Authority based upon information
				submitted by the hospital and other sources of information.
3.6. "Discount Contract" means any contract
				for the payment of patient care services between a purchaser or third party
				payor and a hospital which contract establishes discounts to the purchaser or
				third-party payor and which contract is subject to the approval of the
				Authority pursuant to W. Va. Code '16-29-20. Examples of discount contracts
				shall include, but not be limited to, written contracts between a hospital and
				a third party payor or purchaser establishing a discount to the payor or
				purchaser in the form of a percentage reduction in the amount of charges or
				other adjustments that have the effect of decreasing the amount of charges and
				informal arrangements between hospitals and purchasers or third party payors
				which have the effect of decreasing the amount of charges for a group of
				patients.
3.7. "Hospital" means a
				facility subject to licensure as a hospital under the provisions of W. Va. Code
				'16-5B-1
				and any acute care facility operated by the state government which is primarily
				engaged in providing to inpatients, by or under the supervision of physicians,
				diagnostic and therapeutic services for medical diagnosis, treatment and care
				of injured, disabled or sick persons, and does not include state mental health
				facilities or state long-term care facilities.
3.8. "Inflation Factor" means the DRI
				McGraw-Hill "hospital market basket moving average inflation factor" or any
				other generally accepted indicator of the rate of inflation for hospital
				services as approved by the Authority.
3.9. "Interested party" means any individual,
				group or organization which files a written request with the Authority on or
				before the prehearing conference stating that the individual, group or
				organization is aggrieved or is likely to be aggrieved based upon information
				and belief by any act or failure to act by the Authority or by any rule,
				regulation or final order of the Authority and setting forth with particularity
				the basis for such request.
3.10.
				"Median" means the point that divides the distribution of hospitals in a peer
				group into two parts such that an equal number of hospitals fall above and
				below that point. When the number of hospitals is an even number, then the
				average of the two middle scores is taken as the median.
3.11. "Nongovernmental payors" means payors
				for health care services exclusive of payors covered by the Medicare Program,
				Medicaid Program, and any other federal or state governmental program which
				separately establishes rates for hospitals for a group of payors and which
				preempts the Authority from establishing rates for such group.
3.12. "Nonsupervisory employee" means one who
				does not have the authority to hire, transfer, suspend, lay off, recall,
				promote, discharge, assign, reward, or discipline other employees, or the
				responsibility to direct them, or to adjust their grievance, or effectively to
				recommend such action, and who may exercise only authority of a routine or
				clerical nature, and does not require the use of independent
				judgement.
3.13. "Overage" means an
				excess of revenues over the approved revenue limits for the hospital as
				established by the most recent order of the Authority; provided that, any
				proposed justification for such overage in accordance with this rule may not
				offset the amount of any such overage unless and until accepted by order of the
				Authority.