Search
182-550-2900  <<  182-550-3000 >>   182-550-3010

WAC 182-550-3000

Agency filings affecting this section

Payment method—DRG.

(1) The department uses the diagnosis-related group (DRG) payment method to pay for covered inpatient hospital services, except as specified in WAC 388-550-4300 and 388-550-4400.
(2) The department uses the all-patient grouper (AP-DRG) to assign a DRG to each inpatient hospital stay. The department periodically evaluates which version of the AP-DRG to use.
(3) A DRG payment includes all covered hospital services provided to a client during days the client is eligible, but is not limited to:
(a) An inpatient hospital stay.
(b) Outpatient hospital services, including preadmission, emergency room, and observation services related to an inpatient hospital stay and provided within one calendar day of a client's inpatient hospital stay. These outpatient services must be billed on the inpatient hospital claim (see WAC 388-550-6000 (3)(c)).
(c) Any specific service(s), treatment(s), or procedure(s) (such as renal dialysis services) that the admitting hospital is unable to provide and:
(i) The admitting hospital sends the client to another facility or provider for the service(s), treatment(s), or procedure(s) during the client's inpatient hospital stay; and
(ii) The client returns as an inpatient to the admitting hospital.
(d) All transportation costs for an inpatient client when the client requires transportation to another facility or provider for a specific service(s), treatment(s), or procedure(s) that the admitting hospital is unable to provide and:
(i) The admitting hospital sends the client to another facility or provider for the service(s), treatment(s), or procedure(s); and
(ii) The client returns as an inpatient to the admitting hospital.
(4) The department's allowed amount for the DRG payment is determined by multiplying the assigned DRG's relative weight, as determined in WAC 388-550-3100, by the hospital's specific DRG conversion factor. See WAC 388-550-3450. The total allowed amount also includes any high outlier amount calculated for claims.
(5) When directed by the legislature to achieve targeted expenditure levels, as described in WAC 388-550-2800(2), the department may apply an inpatient adjustment factor to each hospital's specific DRG conversion factor rate used in calculating the DRG payment.
(6) The department's DRG payment to a hospital may be adjusted when one or more of the following occur:
(a) For dates of admission before August 1, 2007, a claim qualifies as a DRG high-cost or low-cost outlier, and for dates of admission on and after August 1, 2007, a claim qualifies as a DRG high outlier (see WAC 388-550-3700);
(b) A client transfers:
(i) Before July 1, 2009, from one acute care hospital or distinct unit to another acute care hospital or distinct unit; or
(ii) On and after July 1, 2009 from one acute care hospital or distinct unit to:
(A) Another acute care hospital or distinct unit;
(B) A skilled nursing facility (SNF);
(C) An intermediate care facility;
(D) Home care under the department's home health program;
(E) A long term acute care facility (LTAC);
(F) Hospice (facility-based or in the client's home);
(G) A hospital-based medicare-approved swing bed, or another distinct unit such as a rehabilitation or psychiatric unit (see WAC 388-550-3600); or
(H) A nursing facility certified under medicaid but not medicare.
(c) A client is not eligible for a medical assistance program on one or more days of the hospital stay;
(d) A client has third party liability coverage at the time of admission to the hospital or distinct unit;
(e) A client is eligible for Part B medicare and medicare has made a payment for the Part B hospital charges; or
(f) A client is discharged from an inpatient hospital stay and, within seven calendar days, is readmitted as an inpatient to the same hospital. The department or its designee performs a retrospective utilization review (see WAC 388-550-1700) on the initial admission and the readmission(s) to determine which inpatient hospital stay(s) qualify for DRG payment. Upon the department's retrospective review, an outlier payment may be made if the department determines the claim for combined hospital stays qualifies as a high-cost outlier or high outlier. See WAC 388-550-3700 for DRG high-cost outliers and high outliers.
(7) For dates of admission on and after July 1, 2009, the department pays inpatient claims assigned by the all-patient DRG grouper (AP-DRG) as cesarean section without complications and comorbidities, at the same rate as the vaginal birth with complicating diagnoses.
(8) The department does not pay for a client's day(s) of absence from the hospital.
(9) The department pays an interim billed hospital claim or covered inpatient hospital services provided to an eligible client only when the interim billed claim meets the criteria in WAC 388-550-2900.
(10) The department applies to the payment for each claim all applicable adjustments for client responsibility, any third party liability, medicare, and any other adjustments as determined by the department.
(11) The department pays hospitals in designated bordering cities for allowed covered services as described in WAC 388-550-3900.
(12) The department pays out-of-state hospitals for allowed covered services as described in WAC 388-550-4000.
[WSR 11-14-075, recodified as § 182-550-3000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-550-3000, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090 and 74.09.500. WSR 07-14-055, § 388-550-3000, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-11-077, § 388-550-3000, filed 5/17/05, effective 6/17/05. Statutory Authority: RCW 74.08.090, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-3000, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-3000, filed 12/18/97, effective 1/18/98.]