WAC 388-550-3600   Diagnosis-related group (DRG) payment--Hospital transfers.  The department applies the following payment rules when an eligible client transfers from one acute care hospital or distinct unit to another acute care hospital or distinct unit:

     (1) The department does not pay a hospital for a nonemergency case when the hospital transfers the client to another hospital.

     (2) The department pays a hospital that transfers emergency cases to another hospital, the lesser of:

     (a) The appropriate diagnosis-related group (DRG) payment; or

     (b) For dates of admission:

     (i) Before August 1, 2007, a per diem rate multiplied by the number of medically necessary days the client stays at the transferring hospital. The department determines the per diem rate by dividing the hospital's DRG payment amount for the appropriate DRG by that DRG's average length of stay.

     (ii) On or after August 1, 2007, a per diem rate multiplied by the number of medically necessary days the client stays at the transferring hospital plus one, not to exceed the total calculated DRG-based payment amount including any outlier payment amount. The department determines the per diem rate by dividing the hospital's DRG allowed amount for payment for the appropriate DRG by that DRG's statewide average length of stay for the AP-DRG classification as determined by the department.

     (3) The department uses:

     (a) The hospital's midnight census to determine the number of days a client stayed in the transferring hospital prior to the transfer; and

     (b) The department's length of stay data to determine the number of medically necessary days for a client's hospital stay.

     (4) The department:

     (a) Pays the hospital that ultimately discharges the client to any residence other than a hospital (e.g., home, nursing facility, etc.) the full DRG payment; and

     (b) Applies the outlier payment methodology if a transfer case qualifies:

     (i) For dates of admission before August 1, 2007, as a high-cost or low-cost outlier; and

     (ii) For dates of admission on or after August 1, 2007, as a high outlier.

     (5) The department does not pay a discharging hospital any additional amounts as a transferring hospital if it transfers a client to another hospital (intervening hospital) which subsequently sends the client back.

     (a) The department's maximum payment to the discharging hospital is the full DRG payment.

     (b) The department pays the intervening hospital(s) a per diem payment based on the method described in subsection (2) of this section.

     (6) The department makes all applicable claim payment adjustments to claims for client responsibility, third party liability, medicare, etc.



[Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. 07-14-051, § 388-550-3600, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. 01-16-142, § 388-550-3600, filed 7/31/01, effective 8/31/01. 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. 98-01-124, § 388-550-3600, filed 12/18/97, effective 1/18/98.]