PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 08-01-083.
Title of Rule and Other Identifying Information: The department is amending WAC 388-531-2000 Increased payments for physician-related services for qualified trauma cases.
Hearing Location(s): Blake Office Park East, Rose Room
4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6094), on March 25, 2008, at 10:00 a.m.
Date of Intended Adoption: Not earlier than March 26, 2008.
Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m. on March 25, 2008.
Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by March 18, 2008, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at johnsjl4@dshs.wa.gov.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rule does the following:
• Clearly states the department determines the appropriate payment enhancement percentage for physician trauma services.
• Ensures the deadline for adjusting qualified trauma claims submitted to the health and recovery services administration by physicians and other clinical providers consistent with the deadline for trauma claims submitted by hospitals.
• Adds cross-references to WAC 388-502-0150 (3) and (7) for clarification.
Reasons Supporting Proposal: This revision provides specified clarity, adds rule consistency, and appropriate cross-references about increased payments for physician-related services for qualified trauma cases.
Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500, chapter 43.20A RCW.
Statute Being Implemented: Chapter 43.20A RCW.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Department of social and health services, health and recovery services administration, division of rates and finance, governmental.
Name of Agency Personnel Responsible for Drafting and Implementation: Ayuni Wimpee, 626 8th Avenue, Olympia, WA, (360) 725-1835; and Enforcement: Division of Rates and Finance, 626 8th Avenue, Olympia, WA, (360) 725-1866.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rule change does not impose more than minor costs for small businesses.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Jonell O. Blatt, Rules Manager, Office of Rules and Publications, Division of Legal Services, Health and Recovery Services Administration, P.O. Box 45504, Olympia, WA 98504-5504, phone (360) 725-1571, fax (360) 586-9727, e-mail blattj@dshs.wa.gov.
February 12, 2008
Stephanie E. Schiller
Rules Coordinator
3947.1(2) Beginning with services provided after June 30, 2003, 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.
(3) 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 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, 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 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 injury.
(b) For hospital-based services only.
(c) Only for 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
department fee-for-service rate for qualified trauma services,
((subject to the following:)) or other payment enhancement
percentage the department determines as appropriate.
(i) 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, 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.
(6) The department distributes increased payments from the TCF only:
(a) When eligible trauma claims are submitted with the appropriate trauma indicator within the time frames specified by 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 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 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:
(a) The department may consider a request for a claim adjustment submitted by a provider only if the claim is received by the department within one year from the date of the initial trauma service;
(b) The department does not allow any carryover of
liabilities for an increased payment from the TCF ((after a
date specified by the department as the last date to make))
beyond three hundred sixty-five days from the date of service.
The deadline for making adjustments to a trauma claim for an
SFY is the same as the deadline for submitting the initial
claim to the department as specified in WAC 388-502-0150(3). WAC 388-502-0150(7) does not apply ((in this case)) to TCF
claims;
(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 the department in a biennium cannot exceed the amount appropriated by the legislature for that biennium. The department has the authority to take whatever actions are needed to ensure the department stays within the current TCF appropriation (see subsection (4)(e)(i) of this section).
[Statutory Authority: RCW 74.08.090, 74.09.500. 05-20-050, § 388-531-2000, filed 9/30/05, effective 10/31/05; 04-19-113, § 388-531-2000, filed 9/21/04, effective 10/22/04.]