WSR 00-05-111

PROPOSED RULES

DEPARTMENT OF

LABOR AND INDUSTRIES

[ Filed February 16, 2000, 11:41 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 99-41 [99-12-114].

Title of Rule: WAC 296-20-022 Payment of out-of-state providers, 296-21-290 Physical medicine, 296-23A-0230 How does the department or self-insurer pay out-of-state hospitals for hospital services? and new section WAC 296-20-12401 Provider application process.

Purpose: To revise the reimbursement methodology for payment to providers outside the state of Washington who treat or provide other health care related services to Washington injured workers.

Statutory Authority for Adoption: RCW 51.04.020, 51.04.030.

Statute Being Implemented: Chapter 51.36 RCW.

Reasons Supporting Proposal: These WAC changes will provide equity of payment methods between Washington state.

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(s): These rules explain the reimbursement methodologies, coverage and payment policies applicable to health care providers rendering treatment and other related services to injured workers when the provider is located outside of Washington state.

Purpose of rules(s): The purpose of these rules is to clarify that department's rules, coverage and payment policies apply to the injured worker's case regardless of geographic location of the provider.

Anticipated Effects of Rule(s): These rules will provide equity of coverage and payment rules and reimbursement methods for all providers regardless of geographic location.

Proposal Changes the Following Existing Rules: The existing rules allow for different payment methods and rules based on the geographic location of the provider. Based on an agency study and other staff work, the existing rules do not provide equity for all providers. Therefore, the revisions seek to clarify the department's reimbursement methodology as well as coverage and payment policies so that all providers are treated equitably regardless of their geographic location.

No small business economic impact statement has been prepared under chapter 19.85 RCW. Since these rule changes have no economic impact on Washington state providers, there is no small business economic impact for Washington businesses.

This memo is in regards to the economic impact of the department's proposed changes to the rules for reimbursement to providers outside of Washington state who provide health care services to injured Washington state workers. The primary reasons for the changes to chapters 296-20, 296-21, and 296-23A WAC is to provide equity between Washington state health care providers and out-of-state providers. Current rules allow for different payment methods and rules based on the geographic location of the provider. The proposed changes clarify the department's coverage and payment policies as well as its reimbursement methodology so that all providers are treated equally regardless of geographic location.

New rules and rule amendments must meet the requirements of the Regulatory Fairness Act (RFA), chapter 19.85 RCW, and the Administrative Procedure Act (APA), chapter 34.05 RCW. One of the requirements of the RFA is that the economic impact of proposed regulations on small businesses be examined relative to their impact on large businesses. The agency must prepare a small business economic impact statement (SBEIS) when a proposed rule, or rule amendments, have the potential of placing a more than minor economic impact on business. A related requirement in the APA demands an evaluation of the probable costs and benefits of a proposed regulation and that these probable benefits exceed the probable costs: Process referred to as a cost-benefit analysis (CBA).

A number of criteria and exemptions were established for both the SBEIS analysis and the CBA analysis. The RFA directs an agency to carry out an SBEIS if a rule or proposed rule change "will impose more than minor costs on businesses in an industry." An industry is defined as "all of the businesses in this state in any one four-digit standard industrial classification as published by the United States department of commerce." Because the businesses impacted by this rule are outside of Washington state the department is not required to conduct an SBEIS for the proposed rule change. For a similar reason the department is also exempt from carrying out the CBA portion of the APA.

RCW 34.05.328 does not apply to this rule adoption.

Hearing Location: Auditorium, Department of Labor and Industries, 7273 Linderson Way S.W., Tumwater, WA, on March 22, 2000, at 2 to 4 p.m.

Assistance for Persons with Disabilities: Contact Evonne Peryea by March 15, 2000.

Submit Written Comments to: Evonne Peryea, Department of Labor and Industries, P.O. Box 44322, Olympia, WA 98504-4322, fax (360) 902-4249, by March 29, 2000.

Date of Intended Adoption: April 18, 2000.

February 16, 2000

Gary Moore

Director

OTS-3793.1


NEW SECTION
WAC 296-20-12401
Provider application process.

(1) How can a provider obtain a provider account number from the department? In order to receive a provider account number from the department, a provider must:

Complete a provider application;

Sign a provider agreement;

Provide a copy of any practice or other license held;

Complete, sign and return a Form W-9; and

Meet the department's provider eligibility requirements as cited in the department's rules.


Notes: A provider account number is required to receive payment from the department, but is not a guarantee of payment for services.
Self-insured employers may have additional requirements for provider status.

(2) Provider account status definitions.

Active - account information is current and provider is eligible to receive payment.

Inactive - account is not eligible to receive payment based on action by the department or at provider request. These accounts can be reactivated.

Terminated - account is not eligible to receive payment based on action by the department or at provider request. These accounts can not be reactivated.

(3) When may the department inactivate a provider account? The department may inactivate a provider account when:

There has been no billing activity on the account for eighteen months; or

The provider requests inactivation; or

Provider communications are returned due to address changes; or

The department changes the provider application or application procedures; or

Provider does not comply with department request to update information.

(4) When may the department terminate a provider account? The department may terminate a provider account when:

The provider is found ineligible to treat per department rules; or

The provider requests termination; or

The provider dies or is no longer in active business status.

(5) How can a provider reactivate a provider account? To reactivate a provider account, the provider may call or write the department. The department may require the provider to update the provider application and/or agreement or complete other needed forms prior to reactivation. Account reactivation is subject to department review.

If a provider account has been terminated, a new provider application will be required.

[]

OTS-3794.1


AMENDATORY SECTION(Amending WSR 90-04-057, filed 2/2/90, effective 3/5/90)

WAC 296-20-022
Payment of out-of-state providers.

(((1) Beginning February 1, 1987, providers of health services in the bordering states of Oregon and Idaho shall bill and be paid according to the medical aid rules of the state of Washington.

(2) Providers of health services in other states and other countries shall be paid at rates which take into account:

(a) Payment levels allowed under the state of Washington medical aid rules;

(b) Payment levels allowed under workers compensation programs in the provider's place of business; and

(c) The usual, customary, and reasonable charges in the provider's state of business.

(3) In all cases these payment levels are the maximum allowed to providers of health services to workers. Should a health services provider's charge exceed the payment amount allowed under the state of Washington medical aid rules, the provider is prohibited from charging the injured worker for the difference between the provider's charge and the allowable rate. Providers violating this provision are ineligible to treat injured workers as provided by WAC 296-20-015 and are subject to other applicable penalties.

(4) Only those diagnostic and treatment services authorized under the state of Washington medical aid rules may be allowed by the department or self-insurer. As determined by the department of labor and industries, the scope of practice of providers in bordering states may be recognized for payment purposes, except that in all cases WAC 296-20-03002 (Treatment not authorized) shall apply. Specifically, services permitted under workers compensation programs in the provider's state or country of business, but which are not allowed under the medical aid rules of the state of Washington, may not be reimbursed. When in doubt, the provider should verify coverage of a service with the department or self-insurer.

(5) Out-of-state hospitals will be paid according to WAC 296-23A-165.)) (1) How will health care providers outside of Washington state be paid? All health care service providers, regardless of their geographic location, will be paid according to the fee schedule rules, rates, coverage and payment policies as published in the Washington state Medical Aid Rules and Fee Schedules and/or provider bulletins.

(2) Can an injured worker be charged for services? In all cases, the department's maximum allowed fees and payment levels are the maximum payable. If a provider's charge exceeds the maximum amount payable under the department's Medical Aid Rules and Fee Schedules, the provider must not charge the injured worker for the difference. A provider violating this provision may be held ineligible to treat injured workers as provided by department rules and may be subject to other applicable penalties.


Exception: When a provider treats an injured worker for condition(s) unrelated to the worker's accepted industrial injury or illness, the provider may bill the worker or other insurers for the unrelated services only.

(3) What services will be paid to providers outside of Washington? Only those diagnostic and treatment services authorized under the state of Washington medical aid rules, fee schedules, payment policies, or medical coverage decisions may be authorized or paid by the department or self-insurer. As determined by the department of labor and industries, the scope of practice of providers outside the state of Washington may be recognized for payment purposes. However, in all cases WAC 296-20-03002 (Treatment not authorized) shall apply. Specifically, services not authorized under Washington workers compensation rules, fee schedules, payment policies, or medical coverage decisions will not be paid, even if permitted under workers compensation program in the provider's state or country of business. When in doubt, the provider should verify coverage of a service with the department or self-insurer.

[Statutory Authority: RCW 51.04.020(4) and 51.04.030. 90-04-057, 296-20-022, filed 2/2/90, effective 3/5/90; 87-24-050 (Order 87-23), 296-20-022, filed 11/30/87, effective 1/1/88; 87-03-004 (Order 86-45), 296-20-022, filed 1/8/87.]

OTS-3795.1


AMENDATORY SECTION(Amending WSR 93-16-072, filed 8/1/93, effective 9/1/93)

WAC 296-21-290
Physical medicine.

((The department or self-insurer will authorize and pay for physical medicine services only when the services are under the direct, continuous supervision of a physician who is "board qualified" in the field of physical medicine and rehabilitation, (except for subsections (1) and (2) of this section). The services must be carried out by the physician or registered physical therapist or a physical therapist assistant serving under the direction of a registered physical therapist, by whom he is employed.

The department or self-insurer will allow other licensed physicians to provide physical medicine modalities in the following situations:

(1) The primary attending physician may administer physical therapist modalities as listed under 97010 - 97039 and/or procedures as listed under 97110 - 97145 in the office. No more than six such visits will be authorized and paid to the attending physician. If the worker requires treatment beyond six visits, he/she must be referred to a registered physical therapist or a physiatrist for such treatment. The attending physician can bill an office visit in addition to the physical therapy visit for the same day if indicated. Refer to the department billing instructions regarding how to bill the physical therapy portion of the visit.

(2) In remote areas, where no registered physical therapist or physical therapist assistant is available, treatment by the attending physician with modalities listed under 97110 - 97145 may be billed under 1044M.

The codes, reimbursement levels, and other policies for physical medicine services are listed in the fee schedules.)) (1) Whom does the department authorize and pay for physical medicine or physical therapy services? The department or self-insurer may authorize and pay for physical medicine services from the following providers:

A medical or osteopathic physician who is "board certified or board qualified" in the field of physical medicine and rehabilitation; or

A licensed physical therapist; or

The injured worker's attending doctor, within the limitations listed below.

The physical medicine services must be personally performed by the:

Physical medicine and rehabilitation physician; or

Attending doctor; or

Licensed physical therapist; or

Physical therapist assistant employed by and serving under the direction of a registered physical therapist, physical medicine and rehabilitation physician, or attending doctor.


Note: Licensed physical therapy provider rules are contained in chapter 296-23 WAC.


(2) When may the department or self-insurer pay the attending doctor for physical medicine services? The department or self-insurer may pay the attending doctor to provide physical medicine modalities and/or procedures in the following situations:

(a) The attending doctor's scope of practice includes physical medicine modalities and procedures.

(b) Only the physical medicine modalities and procedures allowed under the department's fee schedules and payment policies will be authorized or paid.

(c) No more than six physical medicine visits may be authorized and paid to the attending doctor. If the worker requires treatment beyond six visits, the worker must be referred to a licensed physical therapist or a board certified or qualified physical medicine and rehabilitation physician for such treatment. Payments will be made in accordance with the department's fee schedules and payment policies.

(d) In remote areas, where no physical medicine and rehabilitation specialist, licensed physical therapist or physical therapist assistant is available, physical medicine visits required by the patient's accepted condition(s) may be authorized and paid to the attending doctor. Payments will be made in accordance with the department's fee schedules and payment policies.

(e) The attending doctor may bill for office visits in addition to the physical medicine services only when a separately identifiable office visit service is provided in addition to the physical medicine service.

(3) What codes and fees are payable for physical medicine services?

The codes, reimbursement levels, and other policies for physical medicine services are listed in the department's Medical Aid Rules and Fee Schedules. Physicians licensed in physical medicine and licensed physical therapists use CPT and/or HCPCS codes, rules and payment policies as listed in the department's Medical Aid Rules and Fee Schedules or provider bulletins.

Attending doctors must use the local codes, rules and payment policies published in the department's Medical Aid Rules and Fee Schedules or provider bulletins.

[Statutory Authority: RCW 51.04.020, 51.04.030 and 1993 c 159. 93-16-072, 296-21-290, filed 8/1/93, effective 9/1/93.]

OTS-3796.1


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

WAC 296-23A-0230
How does the department or self-insurer pay out-of-state hospitals for hospital services?

The department or self-insurer pays out-of-state hospitals for hospital services using a percent of allowed charges (POAC) factor or department fee schedule. The POAC factor may differ for services performed in inpatient and outpatient settings. ((The department or self-insurer will pay out-of-state hospitals according to the following table:)) Payment rates to hospitals located outside of Washington state are calculated by multiplying the out-of-state percent of allowed charges factor (POAC) by the allowed charges.

Amount paid = (out-of-state POAC Factor) X (Allowed Charges).

Out-of-state hospital providers should bill and the department or self-insurer will pay out-of-state hospitals services according to the following table:


((Hospital Location (State) Hospital Outpatient Services Hospital Inpatient Services
Oregon and Idaho Hospital outpatient radiology, pathology and laboratory, and physical therapy services are to be billed and will be paid using the appropriate Labor and Industries fee scheduled procedure codes.

All other hospital outpatient services will be paid at the Washington state-wide average percent of allowed charges (POAC) factor.

Washington state-wide average percent of allowed charges (POAC) factor.
Hospitals not in Oregon, Idaho or Washington Hospital outpatient radiology, pathology and laboratory, and physical therapy services are paid 100% of allowed charges.

All other hospital outpatient services are paid 97% of allowed charges.

97% of allowed charges.))

Hospital Professional and Ambulance Services Hospital Outpatient Services Hospital Inpatient Services
Professional and ambulance services should be billed with CPT and HCPCS codes on HCFA 1500 forms under separate provider numbers.


These services will be paid using the fee schedule rates and payment policies stated in the Washington Medical Aid Rules and Fee Schedules.

All hospital outpatient services should be billed on UB forms under the hospital provider number with revenue codes.


These services will be paid at the out-of-state percent of allowed charges (POAC) factor as stated in the Washington Medical Aid Rules and Fee Schedules.

All hospital inpatient services should be billed on UB forms under the hospital provider number using revenue codes.


These services will be paid at the out-of-state percent of allowed charges (POAC) factor as stated in the Washington Medical Aid Rules and Fee Schedules.

Military and veteran's administration professional and ambulance services should be billed on HCFA 1500 forms and will be paid at 100% of allowed charges. Military, veteran's administration, health maintenance organization, children's, and state-run psychiatric hospitals will be paid at 100% of allowed charges for outpatient hospital services. Military, veteran's administration, health maintenance organization, children's, and state-run psychiatric hospitals will be paid at 100% of allowed charges for inpatient hospital services.

[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080. 97-06-066, 296-23A-0230, filed 2/28/97, effective 4/1/97.]

Washington State Code Reviser's Office