Current through Register Vol. 24-18, September 15, 2024
(1) The health
care authority's physician trauma care fund (TCF) is an amount that is
legislatively appropriated to the medicaid agency each biennium for the purpose
of increasing the agency's payment to physicians and other clinicians (those
who are performing services within their licensed and credentialed scope of
practice) providing qualified trauma care services to medical assistance
clients covered under the agency's medical assistance programs.
(2) Trauma care services provided to clients
in:
(a) Medicaid, disability lifeline (DL),
incapacity-based medical care services (MCS), children's health insurance
program (CHIP), and apple health for kids, qualify for enhanced rate payments
from the TCF. Trauma care services provided to a DL or MCS client qualify for
enhanced rates only during the client's certification period. See WAC
182-504-0010;
(b) The alien
emergency medical (AEM), refugee assistance, and alien medical programs do not
qualify for enhanced rate payments from the TCF; and
(c) The agency's managed care programs
qualify for enhanced rate payments from the TCF, effective with dates of
service on and after July 1, 2012.
(3) To receive payments from the TCF, a
physician or other clinician must:
(a) Be on
the designated trauma services response team of any department of health
(DOH)-designated or DOH-recognized trauma service center;
(b) Meet the provider requirements in this
section and other applicable rules;
(c) Meet the billing requirements in this
section and other applicable rules; and
(d) Submit all information the agency
requires to monitor the trauma program.
(4) Except as described in subsection (5) of
this section and subject to the limitations listed, the agency makes payments
from the TCF to physicians and other clinicians:
(a) For only those trauma services that are
designated by the agency as "qualified." Qualified trauma care services
include:
(i) Follow-up surgical services
provided within six months of the date of the injury. These surgical procedures
must have been planned during the initial acute episode of injury;
and
(ii) Physiatrist services
provided during an inpatient stay immediately following, and within six months
of, the qualifying traumatic injury.
(b) For hospital-based professional
services-only, and for follow-up surgeries performed in a medicare-certified
ambulatory surgery center (ASC). The follow-up surgery must have been performed
within six months of the initial traumatic injury.
(c) Only for trauma cases that meet the
injury severity score (ISS) (a summary rating system for traumatic anatomic
injuries) criteria specified by the agency. The current qualifying ISS are:
(i) Thirteen or greater for an adult trauma
patient (a client age fifteen or older); and
(ii) Nine or greater for a pediatric trauma
patient (a client younger than age fifteen).
(d) On a per-client basis in any
DOH-designated or DOH-recognized trauma service center.
(e) At a rate of two and one-half times the
agency's current fee-for-service rate for qualified trauma services, or other
payment enhancement percentage the agency deems appropriate.
(i) The agency monitors the payments from the
TCF during each state fiscal year (SFY) and makes necessary adjustments to the
rate to ensure that total payments from the TCF for the SFY will not exceed the
legislative appropriation for that SFY.
(ii) Laboratory and pathology charges are not
eligible for payments from the TCF. (See subsection (6)(b) of this
section.)
(5)
When a trauma case is transferred from one hospital to another, the agency
makes payments from the TCF to physicians and clinicians, according to the ISS
score as follows:
(a) If the transferred case
meets or exceeds the appropriate ISS threshold described in subsection (4)(c)
of this section, providers who furnish qualified trauma services, whether in
the transferring or receiving facility, are eligible for payments from the
TCF.
(b) If the transferred case is
below the ISS threshold described in subsection (4)(c) of this section, only
providers who furnish qualified trauma services in the receiving hospital are
eligible for payments from the TCF.
(6) The agency makes a TCF payment to a
physician or clinician:
(a) Only when the
provider submits an eligible trauma claim with the appropriate trauma indicator
within the time frames specified by the agency; and
(b) On a per-claim basis. Each qualifying
trauma service and/or procedure on the provider's claim is paid at the agency's
current fee-for-service rate, multiplied by the appropriate payment enhancement
percentage described in subsection (4)(e) of this section. Laboratory and
pathology services and/or procedures are not eligible for payments from the TCF
and are paid at the agency's current fee-for-service rate.
(7) For purposes of the payments from the TCF
to physicians and other clinicians, all of the following apply:
(a) The agency considers a request for a
claim adjustment submitted by a provider only if the agency receives the
adjustment request within three hundred sixty-five days from the date of the
initial trauma service. At its discretion, and with sufficient public notice,
the agency may adjust the deadline for submission and/or adjustment of trauma
claims in response to budgetary or other program needs;
(b) Except as provided in subsection (7)(a)
of this section, the deadline for making adjustments to a trauma claim is the
same as the deadline for submitting the initial claim to the agency as
specified in WAC
182-502-0150(3).
See WAC 182-502-0150(11) and
(12) for other time limits applicable to
trauma claims;
(c) All claims and
claim adjustments are subject to federal and state audit and review
requirements; and
(d) The total
payments from the TCF disbursed to providers by the agency in an SFY cannot
exceed the amount appropriated by the legislature for that SFY. The agency has
the authority to take whatever actions are needed to ensure the agency stays
within its TCF appropriation (see subsection (4)(e)(i) of this
section).
Statutory Authority:
RCW
41.05.021. 12-14-041, §182-531-2000,
filed 6/27/12, effective 7/28/12. 11-14-075, recodified as §182-531-2000,
filed 6/30/11, effective 7/1/11. Statutory Authority:
RCW
70.168.040,
74.08.090, and
74.09.500. 10-12-013, §
388-531-2000, filed 5/21/10, effective 6/21/10. Statutory Authority:
RCW
74.08.090,
74.09.500, and chapter 43.20A RCW.
08-18-029, § 388-531-2000, filed 8/27/08, effective 9/27/08. Statutory
Authority:
RCW
74.08.090,
74.09.500. 05-20-050, §
388-531-2000, filed 9/30/05, effective 10/31/05; 04-19-113, §
388-531-2000, filed 9/21/04, effective
10/22/04.
