SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Preproposal statement of inquiry was filed as WSR 05-13-134.
Title of Rule and Other Identifying Information: Amend WAC 388-531-2000 Increased payments for physician-related services for qualified trauma cases.
Hearing Location(s): Blake Office Park East (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane, behind Goodyear Tire. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503, on September 27, 2005, at 10:00 a.m.
Date of Intended Adoption: Not earlier than September 28, 2005.
Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail firstname.lastname@example.org, fax (360) 664-6185, by 5:00 p.m. September 27, 2005.
Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by September 23, 2005, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at email@example.com.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department is amending these rules to correct an unnecessarily restrictive element in current WAC that prohibits payments from the department's trauma care fund (TCF) to physicians for services provided to general assistance-unemployable (GA-U) and Alcohol and Drug Addition Treatment and Support Act (ADATSA) clients. It was never legislative intended to restrict TCF payments to physicians who provide services to GA-U and ADATSA clients, since no disproportionate share hospital (DSH) funds are used to pay physicians.
Reasons Supporting Proposal: See Purpose above.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.500.
Statute Being Implemented: RCW 74.08.090, 74.09.500.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Department of Social and Health Services, governmental.
Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1342; Implementation and Enforcement: Ayuni Wimpee, P.O. Box 45510, Olympia, WA 98504-5510, (360) 725-1835.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule amendment and concludes that it will impose no new costs on small businesses. The preparation of a comprehensive small business economic impact statement is not required.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Ayuni Wimpee, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-1835, fax (360) 753-9152, e-mail firstname.lastname@example.org.
August 18, 2005
Andy Fernando, Manager
Rules and Policies Assistance Unit3587.1
(2) Beginning with services provided after June 30, 2003,
MAA)) the department makes increased payments from the TCF
to physicians and other clinical providers who provide trauma
services to Medicaid, GA-U, and ADATSA clients, subject to the
provisions in this section. A provider is eligible to receive
increased payments from the TCF for trauma services provided
to a GA-U or ADATSA client during the client's certification
period only. See WAC 388-416-0010.
MAA)) The department makes increased payments from
the TCF to physicians and other clinical providers who:
(a) Are on the designated trauma services response team of any department of health (DOH)-designated trauma service center;
(b) Meet the provider requirements in this section and other applicable WAC;
(c) Meet the billing requirements in this section and other applicable WAC; and
(d) Submit all information ((
MAA)) the department
requires to ensure trauma services are being provided.
(4) Except as described in subsection (5) of this section
and subject to the limitations listed, ((
MAA)) the department
makes increased payments from the TCF to physicians and other
eligible clinical providers:
(a) For only those trauma services that are designated by
MAA)) the department as "qualified." These qualified
services must be provided to eligible fee-for-service
Medicaid, GA-U, and ADATSA clients. Qualified trauma services
include care provided within six months of the date of injury
for surgical procedures related to the injury if the surgical
procedures were planned during the initial acute episode of
(b) For hospital-based services only.
(c) Only for ((
Medicaid)) trauma cases that meet the
injury severity score (ISS) (a summary rating system for
traumatic anatomic injuries) of:
(i) Thirteen or greater for an adult trauma patient (a client age fifteen or older); or
(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 trauma service center.
(e) At a rate of two and one-half times the current
MAA)) department fee-for-service rate for qualified trauma
services, subject to the following:
MAA)) The department monitors the increased
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 biennium will not exceed the
legislative appropriation for that biennium.
(ii) Laboratory and pathology charges are not eligible for increased payments from the TCF. (See subsection (6)(b) of this section.)
(5) When a trauma case is transferred from one hospital
to another, ((
MAA)) the department makes increased payments
from the TCF to physicians and other eligible clinical
providers, 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, eligible providers who furnish qualified trauma services in both the transferring and receiving hospitals are eligible for increased payments from the TCF.
(b) If the transferred case is below the ISS threshold described in subsection (4)(c) of this section, only the eligible providers who furnish qualified trauma services in the receiving hospital are eligible for increased payments from the TCF.
MAA)) The department distributes increased payments
from the TCF only:
(a) When eligible trauma claims are submitted with the
appropriate trauma indicator within the timeframes specified
MAA)) the department; and
(b) On a per-claim basis. Each qualifying trauma service
and/or procedure on the physician's claim or other clinical
provider's claim is paid at ((
MAA's)) the department's current
fee-for-service rate, multiplied by an increased TCF payment
rate that is based on the appropriate rate described in
subsection (4)(e) of this section. Charges for laboratory and
pathology services and/or procedures are not eligible for
increased payments from the TCF and are paid at (( MAA's)) the
department's current fee-for-service rate.
(7) For purposes of the increased payments from the TCF to physicians and other eligible clinical providers, all of the following apply:
MAA)) The department may consider a request for a
claim adjustment submitted by a provider only if the claim is
received by (( MAA)) the department within one year from the
date of the initial trauma service;
MAA)) The department does not allow any carryover
of liabilities for an increased payment from the TCF after a
date specified by (( MAA)) the department as the last date to
make adjustments to a trauma claim for an SFY. WAC 388-502-0150(7) does not apply in this case;
(c) All claims and claim adjustments are subject to federal and state audit and review requirements; and
(d) The total amount of increased payments from the TCF
disbursed to providers by ((
MAA)) the department in a biennium
cannot exceed the amount appropriated by the legislature for
that biennium. (( MAA)) The department has the authority to
take whatever actions are needed to ensure (( MAA)) the
department stays within the current TCF appropriation (see
subsection (4)(e)(i) of this section).
[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-19-113, § 388-531-2000, filed 9/21/04, effective 10/22/04.]