HCA to Update Grouper and Weights for Medicaid Outpatient Hospital Payment

March 22, 2017

The Health Care Authority is updating the grouper and weights used to calculate payments for Medicaid outpatient hospital services by prospective payment hospitals. HCA is adopting EAPG grouper version 3.11 and updated weights, effective for services on or after April 1, 2017. HCA is applying an adjustment factor to the updated weights to maintain budget neutrality. There will be no change to hospital-specific rates/EAPG conversion factors. The updated weights better reflect relative changes in costs for specific services. The financial impact for each hospital will depend on the hospital’s mix of services. For more information see our previous Fiscal Watch article.

While the Medicaid managed care plans are working to adopt the new grouper and weights, there may be variations in timing, mainly due to availability of updated vendor software. WSHA recommends that hospitals paid under EAPGs by Medicaid managed care plans contact each of the plans and inquire on how they will implement the changes.  Hospitals should find out when the plans expect to apply the new grouper and weights, if they plan to hold claims, if they anticipate reprocessing of claims, and if there is need for any interim changes to language in the contract. (Andrew Busz, andrewb@wsha.org)


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