Current through Register Vol. 24-18, September 15, 2024
(1) The following definitions and
abbreviations and those found in chapter 182-500 WAC and WAC 182-182-1050 apply
to this section:
(a) "CAH" see "critical
access hospital."
(b) "Cost
settlement" means a reconciliation of the fee-for-service interim CAH payments
with a CAH's actual costs determined in conjunction with the use of the CAH's
final settled medicare cost report (Form 2552-96) after the end of the CAH's
HFY.
(c) "Critical access hospital
(CAH)" means a hospital that is approved by the department of health (DOH) for
inclusion in DOH's critical access hospital program.
(d) "HFY" see "Hospital fiscal
year."
(e) "Hospital fiscal year"
means each individual hospital's medicare cost report fiscal year.
(f) "Interim CAH payment" means the actual
payment the medicaid agency makes for claims submitted by a CAH for service
provided during its current HFY, using the appropriate weighted
costs-to-charges (WCC) rate, as determined by the agency.
(g) "Revenue codes and procedure codes to
cost centers crosswalk" means a document that indicates the revenue codes and
procedure codes that are assigned by each hospital to a specific cost center in
each hospital's medicare cost report.
(h) "Weighted costs-to-charges (WCC) rate"
means a rate the agency uses to determine a CAH payment. See subsection (5) of
this section for how the agency calculates a WCC rate.
(i) "WCC rate" see "weighted costs-to-charges
rate."
(2) To be paid as
a CAH by the agency, a hospital must be approved by the department of health
(DOH) for inclusion in DOH's critical access hospital program. The hospital
must provide proof of CAH status to the agency upon request. A CAH paid under
the CAH program must meet the general applicable requirements in chapter
182-502 WAC. For information on audits and the audit appeal process, see
chapter 182-502A WAC.
(3) The
agency pays an eligible CAH for inpatient and outpatient hospital services
provided to fee-for-service Washington apple health clients on a cost basis
(except when services are provided in a distinct psychiatric unit, a distinct
rehabilitation unit, or detoxification unit), using weighted costs-to-charges
WCC rates and a retrospective cost settlement process. The agency pays CAH
fee-for-service claims subject to retrospective cost settlement, adjustments
such as a third party payment amount, any client responsibility amount,
etc.
(4) For inpatient and
outpatient hospital services provided to clients enrolled in a managed care
organization (MCO) plan, WCC rates for each CAH are incorporated into the
calculations for the managed care capitated premiums. The agency considers
managed care health options and MHD designee WCC payment rates to be cost. Cost
settlements are not performed by the agency for managed care claims.
(5) The agency prospectively calculates
fee-for-service and managed care inpatient and outpatient WCC rates separately
for each CAH.
(a) Before the agency's
calculation of the prospective interim inpatient WCC and outpatient WCC rates
for each hospital participating in the CAH program, the CAH must timely submit
the following to the agency:
(i) Within
twenty working days of receiving the request from the agency, the CAH's
estimated aggregate charge master change for its next HFY;
(ii) At the time that the "as filed" version
of the medicare cost report the CAH initially submits to the medicare fiscal
intermediary for the cost settlement of its most recently completed HFY, a copy
of that same medicare cost report;
(iii) At the same time that the "as filed"
version of the medicare cost report the CAH has submitted to the medicare
fiscal intermediary for cost settlement of its most recently completed HFY, the
CAH's corresponding revenue codes and procedure codes to cost centers crosswalk
that indicates the revenue codes and procedure codes that are assigned by each
hospital to a specific cost center in the hospital's medicare cost
report;
(iv) At the same time that
the "as filed" version of the medicare cost report the CAH has submitted to the
medicare fiscal intermediary for cost settlement of its most recently completed
HFY, a document indicating any differences between the CAH's revenue codes and
procedure codes to cost centers crosswalk and the standard revenue codes and
procedure codes to cost centers crosswalk that the agency provides to the CAH
from the agency's CAH WCC rate calculation model. (For example, a CAH hospital
might indicate when it submits its crosswalk to the agency that a difference
exists in the CAH's placement of statistics for the anesthesia revenue code
normally identified to the anesthesia cost center in the agency's CAH WCC rate
calculation model, but identified to the surgery cost center in the CAH's
submitted medicare cost report.)
(b) The agency:
(i) Determines if differences between the
CAH's crosswalk and the crosswalk in the CAH WCC rate calculation model will be
allowed when the CAH timely submits the document identified in (a)(iii) and
(a)(iv) of this subsection. If the CAH does not timely submit the document, the
agency may use the CAH WCC rate calculation model without considering the
differences.
(ii) Does not allow
unbundling or merging of the standard cost centers identified in the CAH WCC
rate calculation model when the agency calculates the WCC rates. This is a
standard the agency follows during the rate calculation process even though the
CAH hospital may have in contrast to the CAH WCC rate calculation model
indicated multiple cost centers, or merged into fewer costs centers, when
reporting in the medicare cost report. (For example, a CAH reports to the
agency that in the agency's standard radiology cost center grouping in the CAH
WCC rate calculation model, the hospital has established three costs centers in
the medicare cost report, which are radioisotopes, radiology therapeutic, and
radiology diagnostic. During the rate calculation process, the agency combines
these three cost centers under the standard radiology cost center grouping. No
unbundling of the standard cost center grouping is allowed.)
(c) The agency:
(i) Obtains from its medicaid management
information system (MMIS), the following fee-for-service summary claims data
submitted by each CAH for services provided during the same HFY identified in
(a)(ii) of this subsection:
(A) Washington
apple health program codes;
(B)
Inpatient and outpatient hospital claim types;
(C) Procedure codes (for outpatient hospital
claims only), revenue codes, and diagnosis related group (DRG) codes (for
inpatient claims only);
(D) Claim
allowed charges, third party liability, client paid amounts, and agency paid
amounts; and
(E) Units of
service.
(ii) Obtains
Level III trauma payment data from the department of health (DOH).
(iii) Obtains the costs-to-charges ration
(CCR) of each respective cost center from the "as filed" version of the
medicare cost report identified in (a)(ii) of this subsection, supplemented by
any crosswalk information as described in (a)(iii) and (a)(iv) of this
subsection.
(iv) Obtains from the
managed care encounter data the following data submitted by each CAH for
services provided during the same HFY identified:
(A) Washington apple health program
codes;
(B) Inpatient and outpatient
hospital claim types;
(C) Procedure
codes (for outpatient hospital claims only), revenue codes, and diagnosis
related group (DGR) codes (for inpatient claims only); and
(D) Claim allowed charges.
(v) Separates the inpatient claims
data and outpatient hospital claims data;
(vi) Obtains the cost center claim allowed
charges by classifying inpatient and outpatient hospital claim allowed charges
from (c)(i) and (c)(iv) of this subsection billed by a CAH (using any one of,
or a combination of, procedure codes, revenue codes, or DRG codes) into the
related cost center in the CAH's "as filed" medicare cost report the CAH
initially submits to the agency.
(vii) Uses the claims classifications and
cost center combinations as defined in the agency's CAH WCC rate calculation
model;
(viii) Assigns a CAH that
does not have a cost center ratio that CAH's cost center average;
(ix) Allows changes only if a revenue codes
and procedure codes to cost centers crosswalk has been timely submitted (see
(a)(iii), (a)(iv), and (b)(i) of this subsection) and a cost center average is
being used;
(x) Does not allow an
unbundling of cost centers (see (b)(ii) of this subsection);
(xi) Determines the agency-weighted costs for
each cost center by multiplying the cost center's claim allowed charges from
(c)(i) and (c)(iv) of this subsection for the appropriate inpatient or
outpatient claim type by the related service costs center ratio;
(xii) Sums all:
(A) Claim allowed charges from (c)(i) and
(c)(iv) of this subsection separately for inpatient hospital claims.
(B) Claim allowed charges from (c)(i) and
(c)(iv) of this subsection separately for outpatient hospital claims.
(xiii) Sums all:
(A) Agency-weighted costs from (c)(xi) of
this subsection separately for inpatient hospital claims.
(B) Agency-weighted costs from (c)(xi) of
this subsection separately for outpatient hospital claims.
(xiv) Multiplies each hospital's total
agency-weighted costs from (c)(xiii) of this subsection by the centers for
medicare and medicaid services (CMS) medicare market basket inflation rate to
update costs from the HFY to the rate setting period. The medicare market
basket inflation rate is published and updated by CMS periodically;
(xv) Multiplies each hospital's total claim
allowed charges from (c)(xii) of this subsection by the CAH estimated charge
master change from (a)(i) of this subsection. If the charge master change
factor is not submitted timely by the hospital (see (a)(i) of this subsection),
the agency will apply a reasonable alternative factor; and
(xvi) Determines:
(A) The inpatient WCC rates by dividing the
calculation result from (c)(xiv) of this subsection by the calculation result
from (c)(xv) of this subsection.
(B) The outpatient WCC rates by dividing the
calculation result from (c)(xiv) of this subsection by the calculation result
from (c)(xv) of this subsection.
(6) For a currently enrolled hospital
provider that is new to the CAH program, the basis for calculating initial
prospective WCC rates for inpatient and outpatient hospital claims for:
(a) Fee-for-service clients is:
(i) The hospital's most recent "as filed"
medicare cost report; and
(ii) The
appropriate MMIS summary claims data for that HFY.
(b) MCO clients is:
(i) The hospital's most recent "as filed"
medicare cost report; and
(ii) The
appropriate managed care encounter data for that HFY.
(7) For a newly licensed hospital
that is also a CAH, the agency uses the current statewide average WCC rates for
the initial prospective WCC rates.
(8) For a CAH that comes under new ownership,
the agency uses the prior owner's WCC rates until:
(a) The new owner submits its first "as
filed" medicare cost report to the medicare fiscal intermediary, and at the
same time to the agency, the documents identified in (5)(a)(i) through (a)(iv)
of this section; and
(b) The agency
has calculated new WCC rates based on the new owner's "as filed" medicare cost
report and other timely submitted documents.
(9) In addition to the prospective managed
care inpatient and outpatient WCC rates, the agency:
(a) Incorporates the WCC rates into the
calculations for the agency's MCO capitated premium that will be paid to the
MCO plan; and
(b) Requires all MCO
plans having contract relationships with CAHs to pay inpatient and outpatient
WCC rates applicable to managed care claims. For purposes of this section, the
agency considers the WCC rates used to pay CAHs for care given to clients
enrolled in an MCO plan to be cost. Cost settlements are not performed for
claims that are submitted to the MCO plans.
(10) For fee-for-service claims only, the
agency uses the same methodology as outlined in subsection (5) of this section
to perform an interim retrospective cost settlement for each CAH after the end
of the CAH's HFY, using "as filed" medicare cost report data from that HFY that
is being cost settled, the other documents identified in subsection (5)(a)(i),
(a)(iii) and (a)(iv) of this section, when data from the MMIS related to
fee-for-service claims. Specifically, the agency:
(a) Compares actual agency total interim CAH
payments to the agency-weighted CAH fee-for-service costs for the period being
cost settled. (Interim payments are the sum of third party liability/client
payments, agency claim payments, and Level III trauma payments); and
(b) Pays the hospital the difference between
CAH costs and interim CAH payments if actual CAH costs are determined to exceed
the total interim CAH payments for that period. The agency recoups from the
hospital the difference between CAH costs and interim CAH payments if actual
CAH costs are determined to be less than total interim CAH payments.
(11) The agency performs finalized
cost settlements using the same methodology as outlined in subsection (10) of
this section, except that the agency uses the hospital's "final settled"
medicare cost report instead of the initial "as filed" medicare cost report for
the HFY being cost settled. The "final settled" medicare cost report received
from the medicare fiscal intermediary must be submitted by the CAH to the
agency by the sixtieth day of the hospital's receipt of that medicare cost
report.
(12) A CAH must have and
follow written procedures that provide a resolution to complaints and
grievances.
(13) To ensure quality
of care:
(a) A CAH is responsible to
investigate any reports of substandard care or violations of the hospital's
medical staff bylaws; and
(b) A
complaint or grievance regarding substandard conditions or care may be
investigated by any one or more of the following:
(i) Department of health (DOH); or
(ii) Other agencies with review authority for
agency programs.
(14) The agency pays detoxification units,
distinct psychiatric units, and distinct rehabilitation units operated by CAH
hospitals using inpatient payment methods other than WCC rates and cost
settlement.
(a) For dates of admission before
August 1, 2007, the agency uses the RCW payment method to pay for services
provided in detoxification units, distinct psychiatric units, and distinct
rehabilitation units. The exception is for state-administered programs'
psychiatric claims, which are paid using:
(i)
The DRG payment method for claims grouped to stable DRG relative weights
(unless the claim has an HIV-related diagnosis), and in conjunction with the
base community psychiatric hospitalization payment method; or
(ii) The RCW payment method for other
psychiatric claims (except for DRGs 469 and 470), in conjunction with the base
community psychiatric hospitalization payment method.
(b) For dates of admission after July 31,
2007, the agency uses the per diem payment method to pay for services provided
in detoxification units, distinct psychiatric units, and distinct
rehabilitation units.
(15) The agency may conduct a post pay or
on-site review of any CAH.
11-14-075, recodified as §182-550-2598, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.08.090,
74.09.500. 07-14-054, §
388-550-2598, filed 6/28/07, effective 8/1/07; 07-03-077, § 388-550-2598,
filed 1/17/07, effective 2/17/07. Statutory Authority:
RCW
74.04.050,
74.08.090,
74.09.5225. 06-04-089, §
388-550-2598, filed 1/31/06, effective 3/3/06; 05-01-026, § 388-550-2598,
filed 12/3/04, effective 1/3/05. Statutory Authority:
RCW
74.08.090,
74.04.050,
74.09.5225, and HB 1162, 2001 2nd
sp.s. c 2. 02-13-099, § 388-550-2598, filed 6/18/02, effective
7/19/02.
