WSR 10-08-087

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed April 6, 2010, 3:17 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 09-24-027.

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, 388-546-3000 Transporting qualified trauma cases, and 388-550-5450 Supplemental distributions to approved trauma service centers.

Hearing Location(s): Office Building 2, Auditorium, DSHS Headquarters, 1115 Washington, Olympia, WA 98504 (public parking at 11th and Jefferson. A map is available at http://www1.dshs.wa.gov/msa/rpau/RPAU-OB-2directions.html or by calling (360) 664-6094), on May 11, 2010, at 10:00 a.m.

Date of Intended Adoption: Not sooner than May 12, 2010.

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 p.m. on May 11, 2010.

Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by April 27, 2010, 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 rule changes will give DSHS greater flexibility in making supplemental trauma payments to providers in order to leverage federal matching funds under the American Recovery and Reinvestment Act (ARRA) and maximize trauma care system reimbursement. It will also clarify existing policy.

Reasons Supporting Proposal: See Purpose statement.

Statutory Authority for Adoption: RCW 70.168.040, 74.08.090, and 74.09.500.

Statute Being Implemented: RCW 70.168.040, 74.08.090, and 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, 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 determined that the proposed rule will not create more than minor costs on small businesses.

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, WAC [WA] 98504-5510, phone (360) 725-1835, fax (360) 753-7315, e-mail wimpea@dshs.wa.gov.

March 31, 2010

Katherine I. Vasquez

Rules Coordinator

4187.3
AMENDATORY SECTION(Amending WSR 08-18-029, filed 8/27/08, effective 9/27/08)

WAC 388-531-2000   Increased payments for physician-related services for qualified trauma cases.   (1) The department's trauma care fund (TCF) is an amount that is legislatively appropriated to DSHS each biennium for the purpose of increasing the department's payment to ((eligible)) physicians and other ((clinical providers for)) clinicians (those who are performing services within their licensed and credentialed scope of practice) providing qualified trauma care services to ((medicaid, general assistance-unemployable (GA-U), and Alcohol and Drug Addiction Treatment and Support Act (ADATSA))) medical assistance clients covered under the department's fee-for-service ((clients. Claims for trauma care provided to clients enrolled in the department's managed care programs are not eligible for increased payments from the TCF)) programs.

(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)) Trauma care services provided to:

(a) Fee-for-service clients in medicaid, general assistance-unemployable (GAU), alcohol and drug addiction treatment and support act (ADATSA), children's health insurance program (CHIP), and apple health for kids, qualify for enhanced rate payments from the TCF. Trauma care services provided to a GAU or ADATSA client qualify for enhanced rates only during the client's certification period. See WAC 388-416-0010;

(b) Clients in the alien emergency medical and alien medical programs do not qualify for enhanced rate payments from the TCF; and

(c) Clients enrolled in the department's managed care programs do not qualify for enhanced rate payments from the TCF.

(3) ((The department makes increased)) To receive payments from the TCF ((to physicians and)), a physician or other ((clinical providers who)) clinician must:

(a) ((Are)) Be on the designated trauma services response team of any department of health (DOH)-designated or DOH-recognized 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)) monitor the trauma ((services are being provided)) program.

(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)) clinicians:

(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 care services include ((care)):

(i) Follow-up surgical services provided within six months of the date of the injury ((for surgical procedures related to the injury if the)). These surgical procedures ((were)) must have been planned during the initial acute episode of injury; and

(ii) Physiatrist services provided during an inpatient stay immediately following, and within six months of, the initial episode of injury.

(b) For hospital-based services only, and for follow-up surgeries performed in a medicare-certified ambulatory surgery center (ASC). The follow-up surgery must have been performed within six months of the initial traumatic injury.

(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 or DOH-recognized trauma service center.

(e) At a rate of two and one-half times the ((current)) department's current fee-for-service rate for qualified trauma services, 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)) clinicians, 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)) either the transferring ((and)) or receiving ((hospitals)) facility 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)) makes a TCF payment to a physician or clinician:

(a) ((When)) Only when the provider submits an eligible trauma ((claims are submitted)) claim 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)) payment enhancement percentage 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)) clinicians, all of the following apply:

(a) The department ((may)) considers a request for a claim adjustment submitted by a provider only if the ((claim is received by the)) department receives the adjustment request within ((one year)) three-hundred sixty-five days from the date of the initial trauma service. At its discretion, and with sufficient public notice, the department may adjust the deadline for submission and/or adjustment of trauma claims in response to budgetary or other program needs;

(b) ((The department does not allow any carryover of liabilities for an increased payment from the TCF beyond three hundred sixty-five days from the date of service.)) Except as provided in subsection (7)(a) of this section, 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 to TCF)) See WAC 388-502-0150 (11) and (12) for other time limits applicable to trauma 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)) its TCF appropriation (see subsection (4)(e)(i) of this section).

[Statutory Authority: RCW 74.08.090, 74.09.500, and chapter 43.20A RCW. 08-18-029, 388-531-2000, filed 8/27/08, effective 9/27/08. 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.]


AMENDATORY SECTION(Amending WSR 04-17-118, filed 8/17/04, effective 9/17/04)

WAC 388-546-3000   Transporting qualified trauma cases.   (((1))) The ((medical assistance administration (MAA))) department does not pay ambulance providers who meet department of health (DOH) criteria for participation in the statewide trauma network an additional amount for transports involving qualified trauma cases described in WAC 388-550-5450. Subject to the availability of trauma care fund (TCF) monies allocated for such purpose, the department may make supplemental payments to these ambulance providers, also known as verified pre-hospital providers.

(((2) Ambulance providers may apply to the department of health (DOH) for possible grants related to transports of qualified trauma cases.))

[Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. 04-17-118, 388-546-3000, filed 8/17/04, effective 9/17/04.]


AMENDATORY SECTION(Amending WSR 08-08-065, filed 3/31/08, effective 5/1/08)

WAC 388-550-5450   Supplemental distributions to approved trauma service centers.   (1) The trauma care fund (TCF) is an amount legislatively appropriated to the department each biennium, at the legislature's sole discretion, for the purpose of supplementing the department's payments to eligible trauma service centers for providing qualified trauma services to ((eligible)) medicaid fee-for-service clients. Claims for trauma care provided to clients enrolled in the department's managed care programs are not eligible for supplemental distributions from the TCF.

(2) ((Beginning with trauma services provided after June 30, 2003,)) The department makes supplemental distributions from the TCF to qualified hospitals, subject to the provisions in this section and subject to legislative action.

(3) To qualify for supplemental distributions from the TCF, a hospital must:

(a) Be designated or recognized by the department of health (DOH) as an approved Level ((1)) I, Level ((2)) II, or Level ((3)) III adult or pediatric 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;

(d) Submit all information the department requires to ((ensure services are being provided)) monitor the program; and

(e) Comply with DOH's Trauma Registry reporting requirements.

(4) Supplemental distributions from the TCF are:

(a) Allocated into five ((fixed)) payment pools ((of equal amounts)). Timing of payments is described in subsection (5) of this section. Distributions from the payment pools to the individual hospitals are determined by first summing each eligible hospital's qualifying payments since the beginning of the service year and expressing this amount as a percentage of total payments to all eligible hospitals for qualifying services provided during the service year to date. For TCF purposes, service year is defined as the state fiscal year. Each hospital's qualifying payment percentage for the service year-to-date is multiplied by the available amount for the service year-to-date, and then the department subtracts what has been allocated to each hospital for the service year-to-date to determine the portion of the current ((quarterly)) payment pool to be paid to each qualifying hospital. This method for determining supplemental distributions to hospitals applies to TCF allotments beginning with state fiscal year (SFY) 2008. ((This method supersedes and preempts the method adopted in rule and effective August 1, 2007.)) Eligible hospitals and qualifying payments are described in (i) through (iii) of this subsection:

(i) Qualifying payments are the department's payments to Level ((1)) I, Level ((2)) II, and Level ((3)) III trauma service centers for qualified medicaid trauma cases since the beginning of the service year. The department determines the countable payment for trauma care provided to medicaid clients based on date of service, not date of payment;

(ii) The department's payments to Level ((1)) I, Level ((2)) II, and Level ((3)) III hospitals for trauma cases transferred in since the beginning of the service year. A Level ((1)) I, Level ((2)) II, or Level ((3)) III hospital that receives a transferred trauma case from any lower level hospital is eligible for the enhanced payment, regardless of the client's injury severity score (ISS)((. An ISS is a summary rating system for traumatic anatomic injuries)); and

(iii) The department's payments to Level ((2)) II and Level ((3)) III hospitals for qualified trauma cases (those that meet or exceed the ISS criteria in subsection (4)(b) of this section) ((that)) transferred by these hospitals ((transferred)) since the beginning of the service year to a ((higher level designated)) trauma service center ((since the beginning of the service year)) with a higher designation level.

(b) Paid only for a medicaid trauma case that meets:

(i) The ISS of thirteen or greater for an adult trauma patient (a client age fifteen or older);

(ii) The ISS of nine or greater for a pediatric trauma patient (a client younger than age fifteen); or

(iii) The conditions of subsection (4)(c).

(c) Made to hospitals, as follows, for a trauma case that is transferred:

(i) A hospital that receives the transferred trauma case qualifies for payment regardless of the ISS if the hospital is designated or recognized by DOH as an approved Level ((1)) I, Level ((2)) II, or Level ((3)) III adult or pediatric trauma service center;

(ii) A hospital that transfers the trauma case qualifies for payment only if:

(A) It is designated or recognized by DOH as an approved Level ((2)) II or Level ((3)) III adult or pediatric trauma service center; and

(B) The ISS requirements in (b)(i) or (b)(ii) of this subsection are met.

(iii) A hospital that DOH designates or recognizes as an approved Level ((4)) IV or Level ((5)) V trauma service center does not qualify for supplemental distributions for trauma cases that are transferred in or transferred out, even when the transferred cases meet the ISS criteria in subsection (4)(b) of this section.

(d) Not funded by disproportionate share hospital (DSH) funds; and

(e) Not distributed by the department to:

(i) Trauma service centers designated or recognized as Level ((4)) IV or Level ((5)) V;

(ii) Critical access hospitals (CAHs), except when the CAH is also a Level ((3)) III trauma service center. Beginning with qualifying trauma services provided in SFY 2007, the department allows a hospital with this dual status to receive distributions from the TCF; or

(iii) Any ((hospital)) facility for follow-up ((surgical)) services related to the qualifying trauma incident but provided to the client after the client has been discharged ((for)) from the initial hospitalization for the qualifying injury.

(5) Distributions for an SFY are ((divided into five "quarters" and)) paid as follows:

(a) ((Each quarterly distribution paid by the department from the TCF totals twenty percent of the amount designated by the department for that SFY;

(b))) The first ((quarterly)) supplemental distribution from the TCF is made three to six months after the SFY begins;

(((c))) (b) Subsequent ((quarterly payments)) distributions are made approximately every two to four months after the first ((quarterly payment)) distribution is made, except as described in subsection (((d))) (c);

(((d))) (c) The (("fifth quarter")) final distribution from the TCF for the same SFY is:

(i) Made ((one year)) after the end of the SFY;

(ii) Based on the SFY that the TCF designated amount relates to; and

(iii) Distributed based on each eligible hospital's percentage of the total payments made by the department to all designated trauma service centers for qualified trauma cases during the relevant ((fiscal year)) SFY.

(6) For purposes of the supplemental distributions from the TCF, all of the following apply:

(a) The department ((may)) considers a provider's request for a trauma claim adjustment ((submitted by a provider)) only if the adjustment request is received by the department within ((one year)) three hundred sixty-five calendar days from the date of the initial trauma service. At its discretion, and with sufficient public notice, the department may adjust the deadline for submission and/or adjustment of trauma claims in response to budgetary program needs;

(b) ((The department does not allow any carryover of liabilities for a supplemental distribution from the TCF beyond three hundred sixty-five calendar days from the date of discharge (inpatient) or date of service (outpatient).)) Except as provided in subsection (6)(a) of this section, the deadline for making adjustments to a trauma claim 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)) See WAC 388-502-0150 (11) and (12) for other time limits applicable 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 supplemental distributions from the TCF disbursed to eligible hospitals by the department in any biennium cannot exceed the amount appropriated by the legislature for that biennium. The department has the authority to take whatever actions necessary to ensure the department stays within the TCF appropriation.

[Statutory Authority: RCW 74.08.090, 74.09.160, 74.09.500, and 70.168.040. 08-08-065, 388-550-5450, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090, 74.09.500. 07-14-090, 388-550-5450, filed 6/29/07, effective 8/1/07; 06-08-046, 388-550-5450, filed 3/30/06, effective 4/30/06; 04-19-113, 388-550-5450, filed 9/21/04, effective 10/22/04.]

Washington State Code Reviser's Office