PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Health and Recover Services Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 05-17-136.
Title of Rule and Other Identifying Information: New WAC 388-550-4670 CPE payment program -- "Hold Harmless" provision and 388-550-4690 Authorization requirements and utilization review for hospitals eligible for CPE payments.
Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane, behind Goodyear Tire. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on May 9, 2006, at 10:00 a.m.
Date of Intended Adoption: Not earlier than May 10, 2006.
Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m., May 9, 2006.
Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by May 5, 2006, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department is proposing these new sections to add a "hold harmless" provision to meet requirements in ESSB 6090 and to describe the authorization requirements and utilization review process for hospitals eligible for certified public expenditure (CPE) payments.
Reasons Supporting Proposal: See Purpose above.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.500.
Statute Being Implemented: RCW 74.08.090, 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: Kathy Sayre, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1342; 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 analyzed the proposed rule and concluded that no new costs will be imposed on businesses affected by them. The preparation of a comprehensive small business economic impact statement is not required.
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, Health and Recovery Services Administration, Olympia, WA 98504-45510 [98504-5510], phone (360) 725-1835, fax (360) 753-9152, e-mail wimpeah@dshs.wa.gov.
March 29, 2006
Andy Fernando, Manager
Rules and Policies Assistance Unit
3653.2(2) As part of the "hold harmless" payment calculation, the department reprices inpatient hospital claims paid during the service year, beginning with service year SFY 2006, to determine how these claims would have been paid under the payment methodologies in effect during SFY 2005.
(3) The department makes the final "hold harmless" calculation after the department receives the hospital's final audited Medicare cost report and audited financial statements for the service year. The department calculates the federally required prospective cost settlement at the same time. Any adjustments to state grants payments due to the cost settlement calculations will be made as payment adjustments to the next year's state grants.
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(2) The department performs utilization reviews of inpatient hospital:
(a) Admissions in accordance with the requirements of 42 CFR 456, subparts A through C; and
(b) Claims for compliance with medical necessity and length of stay (LOS) standards.
(3) CPE inpatient hospital claims that would have been paid by the diagnosis related group (DRG) payment method prior to July 1, 2005:
(a) Are not targeted for retrospective utilization review based on the department's Professional Activity Study (PAS) Length of Stay (LOS) criteria;
(b) Are subject to the department's medical necessity retrospective utilization review process (see WAC 388-550-1700); and
(c) That involve a client's seven-day readmission (see WAC 388-550-1050) are subject to a department retrospective utilization review described in WAC 388-550-3000 (5)(e).
(4) CPE inpatient hospital claims that would have been paid by the ratio of costs-to-charges (RCC) payment method prior to July 1, 2005 and exceed the Professional Activity Study (PAS) average LOS, will continue to be targeted for retrospective utilization review based on the department's PAS LOS criteria. See WAC 388-550-4300(3).
(5) For claims identified in subsection (4) of this section, the department may request a copy of the client's hospital medical records and itemized billing statements. The department sends written notification to the hospital detailing the department's findings. Any day of a client's hospital stay that exceeds the PAS LOS:
(a) Is paid under the RCC payment method if the department determines it to be medically necessary for the client at the acute level of care;
(b) Is paid as an administrative day (see WAC 388-550-1050 and 388-550-4500(8)) if the department determines it to be medically necessary for the client at the subacute level of care; and
(c) Is not eligible for payment if the department determines it was not medically necessary.
(6) Inpatient hospital claims that would not have been paid under a prior payment methodology are not eligible for payment under the CPE payment program.
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