Title of Rule: WAC 296-23A-0200, 296-23A-0210, 296-23A-0220, and 296-23A-0240 which deal with inpatient and outpatient hospital reimbursement.

Purpose: To delete portions of WAC 296-23A-0200, 296-23A-0210, 296-23A-0220, and 296-23A-0240 which are duplicative of WAC 296-23A-0230 which deals with reimbursements to hospitals located outside of Washington state.

Statutory Authority for Adoption: RCW 51.04.020, 51.04.030, and 51.36.080.

Statute Being Implemented: RCW 51.04.030.

Summary: Deletion of language relating to out-of-state hospitals from WAC 296-23A-0200, 296-23A-0210, 296-23A-0220, and 296-23A-0240 to provide clarity for providers. It also enables the department to proceed with other rule changes for out-of-state providers, which will be filed via the regular rule-making process.

Reasons Supporting Proposal: Because these changes clarify rule language without changing the intent of WAC 296-23A-0230, this action has no impact on stakeholders.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Evonne Peryea, Tumwater, Washington, (360) 902-6828.

Name of Proponent: [Department of Labor and Industries], governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: Explanation of Rule: These rules explain how the Washington workers' compensation program reimburses hospital inpatient and outpatient charges.

Purpose of Revision: The purpose of the change is to clarify language of several WACs by removing duplicative wording to prevent confusion and to have all language related to out-of-state hospital reimbursement in only one section (WAC 296-23A-0230).

Anticipated Effects: Because the proposal only clarifies existing rules, there is no impact on stakeholders.

Proposal does not change existing rules.

December 22, 1999

Gary Moore

Director

OTS-3623.1

AMENDATORY SECTION(Amending WSR 97-06-066, filed 2/28/97, effective 4/1/97)

WAC 296-23A-0200
How does the department pay for hospital inpatient services?

The department will pay for hospital inpatient services according to the following table:

Hospital Type or Location	Do Diagnosis Related Group (DRG) payment methods apply?	Do per diem payment methods apply?	Do percent of allowed charges (POAC) payment methods apply to hospital inpatient services?
Children's Hospitals	No	No	Yes, paid 100% of allowed charges
Chronic Pain Management Program	Exempt, paid per department agreement.	Exempt, paid per department agreement.	Exempt, paid per department agreement.
Health Maintenance Organizations	No	No	Yes, paid 100% of allowed charges
Military	No	No	Yes, paid 100% of allowed charges
Veterans Administration	No	No	Yes, paid 100% of allowed charges
State psychiatric facility	No	No	Yes, paid 100% of allowed charges
((Hospitals not in Oregon, Idaho or Washington	No	No	Yes, paid 97% of allowed charges
Oregon and Idaho	No	No	Yes, paid the Washington statewide average POAC factor))
Washington rural (Peer Group A)	No	Yes, statewide per diem rates apply for five DRG categories: Chemical dependency, psychiatric, rehabilitation, medical, and surgical DRGs	No
All other Washington hospitals	Yes	Yes, state-wide average per diem rates apply for designated categories: Chemical dependency, psychiatric, rehabilitation, low volume medical, and low volume surgical DRGs	Yes, applies to low cost outlier payments and high cost outlier payments above the high cost outlier threshold

[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080.      97-06-066, § 296-23A-0200, filed 2/28/97, effective 4/1/97.]

Self-insurers will pay for hospital inpatient services using percent of allowed charges (POAC) factors, according to the following table:

Hospital Type or Location	Do percent of allowed charges (POAC) payment methods apply to hospital inpatient services?
Military, Veteran's Administration, Health Maintenance Organizations, State Psychiatric Facilities, Children's Hospitals	Yes, paid 100% of allowed charges
((Hospitals not in Oregon, Idaho or Washington	Yes, paid 97% of allowed charges
Oregon and Idaho	Yes, paid the Washington state-wide average POAC factor))
All other Washington hospitals	Yes, paid the hospital specific POAC factor

[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080.      97-06-066, § 296-23A-0210, filed 2/28/97, effective 4/1/97.]

The department or self-insurer will pay for hospital outpatient services according to the following table:

Hospital Type or Location	Do percent of allowed charges (POAC) payment methods apply?	Does the department's Medical Aid Rules and Fee Schedules apply to hospital outpatient radiology, laboratory, pathology an physical therapy services?
Children's Hospitals	Yes, paid 100% of allowed charges	Yes
Chronic Pain Management Program	Exempt, paid per department agreement	Exempt, paid per department agreement
Health Maintenance Organizations	Yes, paid 100% of allowed charges	Yes
Military	Yes, paid 100% of allowed charges	No, paid 100% of allowed charges
Veterans Administration	Yes, paid 100% of allowed charges	No, paid 100% of allowed charges
State psychiatric facility	Yes, paid 100% of allowed charges	Yes
((Hospitals not in Oregon, Idaho or Washington	Yes, paid 97% of allowed charges	No, paid 100% of allowed charges
Oregon and Idaho	Yes, paid the Washington statewide average POAC	Yes))
Washington rural (Peer Group A)	Yes, applies to hospital outpatient services except radiology, laboratory, pathology and physical therapy	Yes
All other Washington hospitals	Yes, applies to hospital outpatient services except radiology, laboratory, pathology and physical therapy	Yes

Hospitals are reimbursed only for the technical component of rates listed in the fee schedules, for outpatient radiology, pathology and laboratory services.

See chapter 296-23 WAC for rules on radiology, pathology, laboratory, physical therapy and work hardening services.

See WAC 296-20-132 and 296-20-135 for information on the conversion factor used for hospital outpatient services.

[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080.      97-06-066, § 296-23A-0220, filed 2/28/97, effective 4/1/97.]

New hospitals are those open for less than one year prior to the implementation of the department's most recent hospital payment rates.      The department will pay new hospitals according to the following table:

Hospital Type or Location	What Diagnosis Related Group (DRG) base price applies?	What Per Diem Payment Rates Apply?	What percent of allowed charges (POAC) factor applies?
((Oregon and Idaho	Exempt	Exempt	Washington state-wide average POAC
Hospitals not in Oregon, Idaho, or Washington	Exempt	Exempt	Paid 97% of allowed charges))
Military, Veterans Administration, State Psychiatric, Health Maintenance Organization, Children's,	Exempt	Exempt	Paid 100% of allowed charges
Chronic Pain Management Program	Exempt, paid per department agreement	Exempt, paid per department agreement	Exempt, Paid per department agreement
Washington Rural Hospital (Peer Group A)	Exempt	Washington state-wide average per diem rates	Washington state-wide average POAC
Other Washington Hospital	Weighted median case-mix adjusted average cost per case for Washington DRG hospitals, except major teaching hospitals	Washington state-wide average per diem rates	Washington state-wide average POAC

A new hospital will be paid using its hospital-specific POAC within three years of receiving a provider account number(s) from the department.

[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080.      97-06-066, § 296-23A-0240, filed 2/28/97, effective 4/1/97.]

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