Date of Adoption: December 1, 2000.

Purpose: Update WAC 296-23A-0500 to reflect current procedures for payment of high outlier cases under the department's hospital inpatient prospective payment system

Citation of Existing Rules Affected by this Order: Amending WAC 296-23A-0500.

Statutory Authority for Adoption: RCW 51.04.020, 51.04.030.

Adopted under notice filed as WSR 00-19-091 on September 20, 2000.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

December 1, 2000

Gary Moore

Director

OTS-4388.1

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

WAC 296-23A-0500   When does a case qualify for high outlier status?   Outlier payments apply only to diagnosis-related-group (DRG) reimbursed cases with unusually high or low costs.      Outlier status does not apply to cases paid using a percent of allowed charges (POAC) factor or per diem rates. ((To have a bill considered for outlier status, a hospital must enter "61" for the condition code, block 35 of the hospital billing form.))

     A case is considered a high cost outlier if the costs for the case exceed the outlier threshold for the assigned diagnosis-related-group.      The costs for a case are determined by multiplying the allowed charges for the case by the hospital specific POAC factor.      The threshold used to define a high outlier case is the greater of a dollar threshold of twelve thousand dollars or two standard deviations above the state-wide average cost for each DRG paid by the department.

     The dollar threshold may be adjusted annually for inflation or other factors as determined by the department.      The standard deviations for DRGs will be computed from all relevant cases in the historical data base, excluding statistical outliers.

[Statutory Authority: RCW 51.04.020, 51.04.030 and 51.36.080.      97-06-066, § 296-23A-0500, filed 2/28/97, effective 4/1/97.]

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