WSR 04-13-048

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed June 10, 2004, 4:41 p.m. , effective July 11, 2004 ]


Purpose: The rule will allow the department to use a broader database for calculating relative weights for the diagnostic-related group (DRG) formula.

Citation of Existing Rules Affected by this Order: Amending WAC 388-550-3100.

Statutory Authority for Adoption: RCW 74.08.090, 74.04.050.

Adopted under notice filed as WSR 04-08-123 on April 7, 2004.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

Date Adopted: June 10, 2004.

Brian H. Lindgren, Manager

Rule and Policies Assistance Unit

3391.2
AMENDATORY SECTION(Amending WSR 99-06-046, filed 2/26/99, effective 3/29/99)

WAC 388-550-3100   Calculating DRG relative weights.   (1) ((MAA sets Washington Medicaid-specific DRG relative weights, as follows)) This section describes how the medical assistance administration (MAA) calculates Washington diagnostic-related group (DRG) relative weights, MAA:

(a) ((Uses)) Classifies the Washington hospital admissions data using the all-patient grouper (AP-DRG) ((to classify Washington Medicaid hospital admissions data)).

(b) Statistically tests each DRG for adequacy of sample size to ensure that relative weights meet acceptable reliability and validity standards.

(c) Establishes a single set of Medicaid-specific relative weights from Washington ((Medicaid)) hospital admissions data. These relative weights may be stable or unstable.

(d) Tests the stability of ((Washington Medicaid )) the relative weights from subsection (1)(c) of this section using a reasonable statistical test to determine if the weights are stable. MAA accepts as stable and adopts those ((Washington Medicaid)) relative weights that pass the reasonable statistical test.

(e) ((Pays admissions for DRGs having unstable Washington Medicaid relative weights using the RCC method)) May compare the Medicaid-specific relative weights to non-Medicaid relative weights. MAA:

(i) May combine the Medicaid-specific relative weights with the non-Medicaid relative weights if the non-Medicaid relative weights are statistically comparable to the Medicaid-specific weights; or

(ii) Uses only the Medicaid-specific relative weights if the non-Medicaid relative weights are not statistically comparable to the Medicaid-specific relative weights.

(f) Uses the ratio of costs-to-charges (RCC) method to pay for hospital stays that have unstable DRG relative weights.

(2) When using ratios with a ((Washington Medicaid )) DRG relative weight as base, MAA adjusts all stable ((Medicaid)) relative weights so that the average weight of the case mix population equals 1.0.

[Statutory Authority: RCW 74.08.090, 42 USC 1395 x(v), 42 CFR 447.271, 447.11303, and 447.2652. 99-06-046, 388-550-3100, filed 2/26/99, effective 3/29/99. 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, 388-550-3100, filed 12/18/97, effective 1/18/98.]

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