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. 13, March 29, 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.
