Section 182-531-2000 - Increased payments for physician-related services for qualified trauma cases(1) The health care authority's physician trauma care fund (TCF) is an amount that is legislatively appropriated to the medicaid agency each biennium for the purpose of increasing the agency's payment to physicians and other clinicians (those who are performing services within their licensed and credentialed scope of practice) providing qualified trauma care services to medical assistance clients covered under the agency's medical assistance programs.(2) Trauma care services provided to clients in:(a) Medicaid, disability lifeline (DL), incapacity-based medical care services (MCS), 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 DL or MCS client qualify for enhanced rates only during the client's certification period. See WAC 182-504-0010;(b) The alien emergency medical (AEM), refugee assistance, and alien medical programs do not qualify for enhanced rate payments from the TCF; and(c) The agency's managed care programs qualify for enhanced rate payments from the TCF, effective with dates of service on and after July 1, 2012.(3) To receive payments from the TCF, a physician or other clinician must: (a) 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 rules;(c) Meet the billing requirements in this section and other applicable rules; and(d) Submit all information the agency requires to monitor the trauma program.(4) Except as described in subsection (5) of this section and subject to the limitations listed, the agency makes payments from the TCF to physicians and other clinicians: (a) For only those trauma services that are designated by the agency as "qualified." Qualified trauma care services include: (i) Follow-up surgical services provided within six months of the date of the injury. These surgical procedures 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 qualifying traumatic injury.(b) For hospital-based professional 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) criteria specified by the agency. The current qualifying ISS are: (i) Thirteen or greater for an adult trauma patient (a client age fifteen or older); and(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 agency's current fee-for-service rate for qualified trauma services, or other payment enhancement percentage the agency deems appropriate. (i) The agency monitors the 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 SFY will not exceed the legislative appropriation for that SFY.(ii) Laboratory and pathology charges are not eligible for payments from the TCF. (See subsection (6)(b) of this section.)(5) When a trauma case is transferred from one hospital to another, the agency makes payments from the TCF to physicians and 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, providers who furnish qualified trauma services, whether in the transferring or receiving facility, are eligible for payments from the TCF.(b) If the transferred case is below the ISS threshold described in subsection (4)(c) of this section, only providers who furnish qualified trauma services in the receiving hospital are eligible for payments from the TCF.(6) The agency makes a TCF payment to a physician or clinician: (a) Only when the provider submits an eligible trauma claim with the appropriate trauma indicator within the time frames specified by the agency; and(b) On a per-claim basis. Each qualifying trauma service and/or procedure on the provider's claim is paid at the agency's current fee-for-service rate, multiplied by the appropriate payment enhancement percentage described in subsection (4)(e) of this section. Laboratory and pathology services and/or procedures are not eligible for payments from the TCF and are paid at the agency's current fee-for-service rate.(7) For purposes of the payments from the TCF to physicians and other clinicians, all of the following apply: (a) The agency considers a request for a claim adjustment submitted by a provider only if the agency receives the adjustment request within three hundred sixty-five days from the date of the initial trauma service. At its discretion, and with sufficient public notice, the agency may adjust the deadline for submission and/or adjustment of trauma claims in response to budgetary or other program needs;(b) Except as provided in subsection (7)(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 agency as specified in WAC 182-502-0150(3). See WAC 182-502-0150(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 payments from the TCF disbursed to providers by the agency in an SFY cannot exceed the amount appropriated by the legislature for that SFY. The agency has the authority to take whatever actions are needed to ensure the agency stays within its TCF appropriation (see subsection (4)(e)(i) of this section).Wash. Admin. Code § 182-531-2000
Statutory Authority: RCW 41.05.021. 12-14-041, §182-531-2000, filed 6/27/12, effective 7/28/12. 11-14-075, recodified as §182-531-2000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 70.168.040, 74.08.090, and 74.09.500. 10-12-013, § 388-531-2000, filed 5/21/10, effective 6/21/10. 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.