(1) The medicaid agency uses the diagnosis-related group (DRG) payment method to pay for covered inpatient hospital services, except as specified in WAC 182-550-4300
(2) The agency assigns a DRG code to each claim for an inpatient hospital stay using 3M™ software (AP-DRG or APR-DRG) or other software currently in use by the agency. That DRG code determines the method used to pay claims for prospective payment system (PPS) hospitals. For the purpose of this section, PPS hospitals include all in-state and border area hospitals, except both of the following:
(a) Critical access hospitals (CAH), which the agency pays per WAC 182-550-2598
(b) Military hospitals, which the agency pays using the following payment methods depending on the revenue code billed by the hospital:
(i) Ratio of costs-to-charges (RCC); and
(ii) Military subsistence per diem.
(3) For each DRG code, the agency establishes an average length of stay (ALOS). The agency may use the DRG ALOS as part of its authorization process and payment methods as specified in this chapter.
(4) An inpatient claim payment includes all hospital covered services provided to a client during days the client is eligible. This includes, but is not limited to:
(a) The inpatient hospital stay;
(b) Outpatient hospital services, including preadmission, emergency department, and observation services related to an inpatient hospital stay and provided within one calendar day of a client's inpatient hospital stay. These outpatient services must be billed on the inpatient hospital claim;
(c) Any hospital covered service for which the admitting hospital sends the client to another facility or provider during the client's inpatient hospital stay, and the client returns as an inpatient to the admitting hospital.
(5) The agency's claim payment for an inpatient stay is determined by the payment method. The agency pays hospitals for inpatient hospital covered services provided to clients using the following methods:
General Description of Payment Formula
DRG (Diagnostic Related Group)
DRG specific relative weight times hospital specific DRG rate times maximum service adjustor
Hospital-specific daily rate for the service (psych, rehab, detox, or CUP) times covered allowable days
Fixed Per Diem for Long Term Acute Care (LTAC)
Fixed LTAC rate per day times allowed days plus ratio of cost to charges times allowable covered ancillaries not included in the daily rate
Ratio of Costs-to-Charges (RCC)
RCC times billed covered allowable charges
Cost Settlement with Ratio of Costs-to-Charges
RCC times billed covered allowable charges (subject to hold harmless and other settlement provisions of the Certified Public Expenditure program)
Cost Settlement with Weighted Costs-to-Charges (WCC)
WCC times billed covered allowable charges subject to Critical Access Hospital settlement provisions
Depending on the revenue code billed by the hospital:
• RCC times billed covered allowable charges; and
• Military subsistence per diem.
Standard administrative day rate times days authorized by the agency combined with RCC times ancillary charges that are allowable and covered for administrative days
(6) For claims paid using the DRG method, the payment may not exceed the billed amount.
(7) The agency may adjust the initial allowable calculated for a claim when one or more of the following occur:
(a) A claim qualifies as a high outlier (see WAC 182-550-3700
(b) A claim is paid by the DRG method and a client transfers from one acute care hospital or distinct unit per WAC 182-550-3600
(c) A client is not eligible for a Washington apple health program on one or more days of the hospital stay;
(d) A client has third-party liability coverage at the time of admission to the hospital or distinct unit;
(e) A client is eligible for Part B medicare, the hospital submitted a timely claim to medicare for payment, and medicare has made a payment for the Part B hospital charges;
(f) A client is discharged from an inpatient hospital stay and, within fourteen calendar days, is readmitted as an inpatient to the same hospital or an affiliated hospital. The agency or the agency's designee performs a retrospective utilization review (see WAC 182-550-1700
) on the initial admission and all readmissions to determine which inpatient hospital stays qualify for payment. The review may determine:
(i) If both admissions qualify for separate reimbursement;
(ii) If both admissions must be combined to be reimbursed as one payment; or
(iii) Which inpatient hospital stay qualifies for individual payment.
(g) A readmission is due to a complication arising from a previous admission (e.g., provider preventable condition described in WAC 182-502-0022
). The agency or the agency's designee performs a retrospective utilization review to determine if both admissions are appropriate and qualify for individual payments; or
(h) The agency identifies an enhanced payment due to a provider preventable condition, hospital-acquired condition, serious reportable event, or a condition not present on admission.
(8) In response to direction from the legislature, the agency may change any one or more payment methods outlined in chapter 182-550
WAC for the purpose of achieving the legislature's targeted expenditure levels. The legislative direction may take the form of express language in the Biennial Appropriations Act or may be reflected in the level of funding appropriated to the agency in the Biennial Appropriations Act. In response to this legislative direction, the agency may calculate an adjustment factor (known as an "inpatient adjustment factor") to apply to inpatient hospital rates.
(a) The inpatient adjustment factor is a specific multiplier calculated by the agency and applied to existing inpatient hospital rates to meet targeted expenditure levels as directed by the legislature.
(b) The agency will apply the inpatient adjustment factor when the agency determines that its expenditures on inpatient hospital rates will exceed the legislature's targeted expenditure levels.
(c) The agency will apply any such inpatient adjustment factor to each affected rate.
(9) The agency does not pay for a client's day of absence from the hospital.
(10) The agency pays an interim billed hospital claim for covered inpatient hospital services provided to an eligible client only when the interim billed claim meets the criteria in WAC 182-550-2900
(11) The agency applies to the allowable for each claim all applicable adjustments for client responsibility, any third-party liability, medicare payments, and any other adjustments as determined by the agency.
(12) The agency pays hospitals in designated bordering cities for allowed covered services as described under WAC 182-550-3900
(13) The agency pays out-of-state hospitals for allowed covered services as described under WAC 182-550-4000
(14) The agency's annual aggregate payments for inpatient hospital services, including payments to state-operated hospitals, will not exceed the estimated amounts that the agency would have paid using medicare payment principles.
(15) When hospital ownership changes, the agency's payment to the hospital will not exceed the amount allowed under 42 U.S.C. Section 1395x (v)(1)(O).
(16) Hospitals participating in the apple health program must annually submit to the agency:
(a) A copy of the hospital's CMS medicare cost report (Form 2552 version currently in use by the agency) that is the official "as filed" cost report submitted to the medicare fiscal intermediary; and
(b) A disproportionate share hospital (DSH) application if the hospital wants to be considered for DSH payments. See WAC 182-550-4900
for the requirements for a hospital to qualify for a DSH payment.
(17) Reports referred to in subsection (16) of this section must be completed according to:
(a) Medicare's cost reporting requirements;
(b) The provisions of this chapter; and
(c) Instructions issued by the agency.
(18) The agency requires hospitals to follow generally accepted accounting principles.
(19) Participating hospitals must permit the agency to conduct periodic audits of their financial records, statistical records, and any other records as determined by the agency.
(20) The agency limits payment for private room accommodations to the semiprivate room rate. Room charges must not exceed the hospital's usual and customary charges to the general public as required by 42 C.F.R. Sec. 447.271.
(21) For a client's hospital stay that involves regional support network (RSN)-approved voluntary inpatient or involuntary inpatient hospitalizations, the hospital must bill the agency for payment. When the hospital contracts directly with the RSN, the hospital must bill the RSN for payment.
(22) For psychiatric hospitals and psychiatric hospital units, when a claim groups to a DRG code that pays by the DRG method, the agency may manually price the claim at the hospital's psychiatric per diem rate.
[Statutory Authority: RCW 41.05.021
. WSR 19-04-004, § 182-550-3000, filed 1/23/19, effective 3/1/19; WSR 18-11-074, § 182-550-3000, filed 5/16/18, effective 7/1/18; WSR 15-24-096, § 182-550-3000, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021
and chapter 74.60
RCW. WSR 14-12-047, § 182-550-3000, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-3000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050
, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-550-3000, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090
. WSR 07-14-055, § 388-550-3000, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.04.050
. WSR 05-11-077, § 388-550-3000, filed 5/17/05, effective 6/17/05. Statutory Authority: RCW 74.08.090
, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-3000, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090
, [74.09.]500, [74.09.]530 and 43.20B.020
. WSR 98-01-124, § 388-550-3000, filed 12/18/97, effective 1/18/98.]