After discussions with WSHA, the Washington State Health Care Authority (HCA) recently announced it will revise its policy on administrative days and return to the longstanding policy it used previously. This revision will ensure hospitals are paid for days where a patient has completed an inpatient stay and no longer meets inpatient criteria, but transfer to an appropriate post-acute care such as a skilled nursing facility is delayed due to capacity issues. WSHA and member hospitals had sought clarification as HCA had been denying these additional stays and forcing hospitals to absorb these costs.
HCA affirmed that authorized services would be paid the administrative day rate. HCA is revising the provider billing guide due October 1 to reflect the change and will also provide additional detail on criteria and billing. We believe HCA intends to pay for prior services that met the criteria but had been denied. We are seeking additional information from HCA on the process for reconsideration of these claims. Some of the Medicaid managed care plans had expressed confusion on the policy, and HCA has notified the plans of the change, through an email and at its September 11 all-plan meeting. Hospitals should contact the plans with issues regarding services to Apple Health enrollees.
We are pleased HCA agreed to the policy clarification and thank staff from various hospitals who helped us provide information to support the revision. (Andrew Busz)
WSHA Weighs In with HCA on Global Waiver Application
On August 21, WSHA provided supportive, but detailed comments, to the Health Care Authority on its global waiver application to the Centers for Medicare & Medicaid Services (CMS). The comment letter focuses on several issues, including sustainability, incentives, the role of Accountable Communities of Health, and evaluation and measurement of projects.
HCA has applied for a Medicaid global waiver to transform care delivery, including long-term care, and improve the focus on population health (click here to read more). HCA is asking CMS for $3 billion over five years in federal funds for this work. CMS and HCA will now enter into a formal negotiation period over the details of the global waiver program. WSHA plans to discuss submitting a comment letter to CMS at its upcoming October 7 Board meeting. (Chelene Whiteaker)
WSHA Comments on Medicare Joint Replacement Bundling Initiative
WSHA recently provided comments to the Centers for Medicare & Medicaid Services on its proposed rule that would make hospitals in selected geographic areas responsible for the total cost and quality of knee and hip replacement surgery, including post-acute care services. For more information regarding the proposal, see our recent Bulletin. WSHA has also provided Washington hospitals in the selected geographic areas with reports to help determine the possible impact for their facility.
In its comment letter to CMS, WSHA recommended CMS recognize differences in cost due to patient acuity and reflect these differences in each hospital’s target rates. Otherwise, some hospitals will be penalized for their mix of cases. In addition, WSHA asked that hospitals be given more tools and protections to enable them to better control the utilization of post-acute care, such as relief from selected regulatory restrictions. WSHA also requested that Washington and other regions with low average costs not be penalized for their past success. Instead of using a regional cost average to set rates, the target rates should incorporate a factor for national average costs. (Andrew Busz)
Draft Pharmacy Rules Pose Risk to Costs, Workflow, Innovation
On August 28, the Washington State Pharmacy Commission released draft rulemaking language that would require every facility have a pharmacist in charge who would spend at least 20 hours, or 50 percent of his or her time, at the pharmacy to which he or she is accountable. We are concerned with the financial burden this would place on facilities and the potential detrimental impact to innovative approaches, like telepharmacy.
While we are still reviewing this language, we have concerns with its nature and direction. WSHA staff expressed these concerns to the Commission at its September 2 Pharmacy Business Practice Meeting and will submit formal comments at a later date. We strongly encourage hospitals and systems to review the draft language, submit comments to the Department of Health here, and let WSHA know your comments. (Ian Corbridge)
Bree Collaborative Responds to Heart Surgery Draft Comments
The Bree Collaborative responded September 1 to public comments on its draft heart surgery report. It appears as if some of our concerns remain unaddressed. The Collaborative will vote to approve a final report at its September 16 meeting. WSHA fully supports efforts to improve patient safety and recovery while reducing costs associated with heart surgery. However, we have some concerns with how the recommendations are calibrated. We appreciate the Collaborative’s attention to this very important issue. (Ian Corbridge)