Current through Register Vol. 24-18, September 15, 2024
The agency uses the payment methods described in this
section to pay bordering city hospitals and critical border hospitals for
inpatient and outpatient claims. Bordering city hospitals and critical border
hospitals are defined in WAC
182-550-1050.
(1) For inpatient hospital claims from
bordering city hospitals, the agency calculates the payment for allowed covered
charges related to medically necessary services, by using the lowest of the
in-state inpatient hospital rates for the:
(a) Diagnosis-related group (DRG) conversion
factor;
(b) Per diem payment
method;
(c) Per case payment
method; and
(d) Ratio of
costs-to-charges (RCC) payment method.
(2) For outpatient hospital claims from
bordering city hospitals, the agency calculates the payment for allowed covered
charges related to medically necessary services, using the lowest of the
in-state outpatient hospital rates for the outpatient prospective payment
system (OPPS). Refer to WAC
182-550-7000 through
182-550-7600.
(3) Designated critical border hospitals.
(a) The agency designates certain qualifying
hospitals located out-of-state as critical border hospitals. A designated
critical border hospital must:
(i) Be a
bordering city hospital as described in WAC
182-550-1050; and
(ii) Have submitted at least ten percent of
the total none-mergency inpatient hospital claims paid to bordering city
hospitals for the prior state fiscal year (SFY) for clients eligible for
Washington apple health. Nonemergency inpa-tient hospital claims are defined as
those that do not include emergency department charges (revenue code 045X
series).
(b) The agency
analyzes bordering city hospitals' base period claims data during the rebasing
process, and annually thereafter, to determine if a bordering city hospital
qualifies or continues to qualify as a critical border hospital.
(4) Critical border hospitals -
Inpatient hospital claim payment methods. The agency pays inpatient critical
border hospital claims as follows:
(a) The
inpatient payment rates used to calculate payments to critical border hospitals
are prospective payment rates. The rates are not used to pay for claims with
dates of admission before the hospital qualified as a critical border
hospital.
(b) The agency pays
inpatient critical border hospital claims using the same payment methods and
rates used for in-state hospital claims, including DRG, RCC, per diem,
outliers, and per case rate, subject to the following:
(i) Inpatient payment rates used to pay
critical border university hospitals for inpatient hospital claims cannot
exceed the highest corresponding inpatient payment rate for an in-state
university hospital;
(ii) Inpatient
payment rates used to pay critical border Level 1 trauma centers for inpatient
hospital claims cannot exceed the highest corresponding inpatient payment rate
for an in-state Level 1 trauma center; and
(iii) Inpatient payment rates used to pay
critical border hospitals that are not university hospitals or Level 1 trauma
centers cannot exceed the highest corresponding in-state inpatient payment rate
for in-state hospitals not designated as university hospitals or Level 1 trauma
centers.
(5)
Critical border hospitals - Outpatient hospital claim payment methods. The
agency pays outpatient critical border hospital claims using the same payment
methods used for in-state outpatient hospital claims (see WAC
182-550-7000 through
182-550-7600 and
182-550-4500) , subject to the
following:
(a) Outpatient rates used to pay
critical border university hospitals for outpatient claims cannot exceed the
highest corresponding rate for an in-state university hospital;
(b) Outpatient rates used to pay critical
border Level 1 trauma centers for outpatient claims cannot exceed the highest
corresponding rate for an in-state Level 1 trauma cen-ter; and
(c) Outpatient rates used to pay critical
border hospitals that are not university hospitals or Level 1 trauma centers
cannot exceed the highest corresponding rate for in-state hospitals not
designated as university hospitals or Level 1 trauma centers.
(6) Critical border hospitals are
eligible to receive payment for graduate medical education (GME). All other
bordering city hospitals are not eligible to receive payment for GME.
(7) The agency makes:
(a) Claim payment adjustments, including but
not limited to, third-party liability, medicare, and client responsibility;
and
(b) Other necessary
adjustments, as directed by the legislature (e.g., rate rebasing and other
changes).
11-14-075, recodified as §182-550-3900, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.04.050,
74.04.057,
74.08.090,
74.09.500, and 2009-11 Omnibus
Operating Budget (ESHB 1244). 09-12-063, § 388-550-3900, filed 5/28/09,
effective 7/1/09. Statutory Authority:
RCW
74.08.090,
74.09.500 and 2005 c 518.
07-14-051, § 388-550-3900, filed 6/28/07, effective 8/1/07. Statutory
Authority: RCW 74.09.090, 42
U.S.C. 1395 x(v) and 1396r-4,
42 C.F.R.
447.271, 11303 and 2652. 99-14-027, §
388-550-3900, filed 6/28/99, effective 7/1/99. Statutory Authority:
RCW
74.08.090,
74.09.730,
74.04.050,
70.01.010,
74.09.200, [74.09.]500,[74.09.]530
and 43.20B.020. 98-01-124, § 388-550-3900, filed 12/18/97, effective
1/18/98.
