HCA to Reprocess Outpatient Hospital Claims

July 7, 2016

The Health Care Authority (HCA) has advised WSHA that a number of outpatient hospital claims paid through the ProviderOne system over the last six weeks were paid at incorrect grouper weights rates and will be reprocessed though a mass adjustment process.  The payment error was made as HCA began to prepare for a July 1st update to its outpatient Enhanced Ambulatory Payment Group (EAPG) payment system.  The weights for the updated EAPG version were applied prematurely and used for the payment of hospitals’ outpatient claims.

The error affects outpatient hospital claims processed and paid under the state’s outpatient prospective payment system between May 17 and June 30, with dates of service on or after February 1.  HCA intends to reprocess the claims through a mass adjustment process to reflect the current version of EAPG weights. Because services may pay more or less under the new weights compared to the existing weights, the impact of the reprocessing will vary by hospital, depending on its mix of services. The error does not affect claims from critical access hospitals or claims processed by the Medicaid managed care plans.

HCA Version 3.11 Update

HCA has been using version 3.7 of the EAPG grouper software and had originally planned to implement a newer version (version 3.11) in July.  HCA is now considering a delay in implementation of the new weights until January 1, 2017.  HCA estimates that aggregate case mix for Medicaid outpatient hospital services will be greater under the new EAPG version 3.11 raw national weights than the weights under the current EAPG version 3.7 national weights and believes an adjustment to rates will be necessary to ensure budget neutrality.  A delay in implementation until January would give an opportunity for communication and discussions with WSHA’s rebasing task force and other stakeholders.  (Andrew Busz, andrewb@wsha.org)


Contact Us

Washington State Hospital Association
999 Third Avenue
Suite 1400
Seattle, WA 98104

Map / Directions

206.281.7211 phone
206.283.6122 fax


Staff List