PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
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 (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.]
(((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.]
(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.]