4123-6-37.2 Payment of hospital outpatient services.

 

 

 

Rule Summary and Fiscal Analysis (Part A)

 

Bureau of Workers' Compensation

Agency Name

 

Tom Sico

Division                                                                  Contact

 

30 West Spring St. L26 Columbus OH 43215-0000	614-466-6600	614-621-3372
Agency Mailing Address (Plus Zip)	Phone	Fax

 

 

4123-6-37.2

Rule Number

NEW

TYPE of rule filing

Rule Title/Tag Line              Payment of hospital outpatient services.

RULE SUMMARY

1.  Is the rule being filed consistent with the requirements of the RC 119.032 review? No

2.  Are you proposing this rule as a result of recent legislation? No

3.  Statute prescribing the procedure in accordance with the agency is required to adopt the rule: 119.03

4.  Statute(s) authorizing agency to adopt the rule: 4121.12, 4121.30, 4121.31, 4123.05

5.  Statute(s) the rule, as filed, amplifies or implements: 4121.121, 4121.44, 4121.441, 4123.66

6.  State the reason(s) for proposing (i.e., why are you filing,) this rule:

The rule is amended to update the methodology for the payment of hospital outpatient services for workers' compensation claims.

7.  If the rule is an AMENDMENT, then summarize the changes and the content of the proposed rule; If the rule type is RESCISSION, NEW or NO CHANGE, then summarize the content of the rule:

This rule outline reimbursement for hospital outpatient services starting May 1,

2010 or after, unless an MCO has negotiated a different payment rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code.

BWC's current hospital outpatient services reimbursement rule is based on a

cost-plus methodology with a cap, utilizing outpatient cost-to-charge ratios (CCR) from Ohio Medicaid as the basis for determining the cost of hospital outpatient services.

BWC is proposing to move from this retrospective cost-plus reimbursement methodology to a prospective payment methodology for hospital outpatient services for 2010, based on a modified version of Medicare's Outpatient Prospective Payment System (OPPS).

BWC is recommending the following changes to OAC 4123-6-37.2: adoption of a modified OPPS

methodology for hospital outpatient reimbursement methodology; adoption of payment adjustment factors to be used with modified OPPS; modification to OPPS 'hold harmless' calculation; and, modification to payment for children's hospitals.

8.  If the rule incorporates a text or other material by reference and the agency claims the incorporation by reference is exempt from compliance with sections

121.71 to 121.74 of the Revised Code because the text or other material is generally available to persons who reasonably can be expected to be affected by the rule, provide an explanation of how the text or other material is generally available to those persons:

This response left blank because filer specified online that the rule does not incorporate a text or other material by reference.

9.  If the rule incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material electronically, provide an explanation of why filing the text or other material electronically was infeasible:

This response left blank because filer specified online that the rule does not incorporate a text or other material by reference.

10.  If the rule is being rescinded and incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material, provide an explanation of why filing the text or other material was infeasible:

Not Applicable.

11.  If revising or refiling this rule, identify changes made from the previously filed version of this rule; if none, please state so:

Not Applicable.

12.  119.032 Rule Review Date:

(If the rule is not exempt and you answered NO to question No. 1, provide the scheduled review date. If you answered YES to No. 1, the review date for this rule is the filing date.)

NOTE: If the rule is not exempt at the time of final filing, two dates are required: the current review date plus a date not to exceed 5 years from the effective date for Amended rules or a date not to exceed 5 years from the review date for No Change rules.

FISCAL ANALYSIS

13.  Estimate the total amount by which this proposed rule would increase / decrease either revenues / expenditures for the agency during the current biennium (in dollars): Explain the net impact of the proposed changes to the budget of your agency/department.

This will have no impact on revenues or expenditures. 0

n/a

14.  Identify the appropriation (by line item etc.) that authorizes each expenditure necessitated by the proposed rule:

n/a

15.  Provide a summary of the estimated cost of compliance with the rule to all directly affected persons. When appropriate, please include the source for your information/estimated costs, e.g. industry, CFR, internal/agency:

With the reimbursement methodology change of this proposed rule, BWC is adjusting hospital outpatient rates to be more aligned with commercial payers. The projected impact is an overall payment decrease of 22% or approximately $30 million. The recommended two year transition plan is estimated to allow half, $15 million, of the impact to occur in 2010 and the second half, $15 million, to occur in 2012. The projected impact is based on 2008 data modeled under the 2009 OPPS

rates. Actual changes in hospital cost, injured worker utilization, or hospital outpatient services and OPPS rates will modify the realized impact of the implementation of this payment methodology. The recommended changes will improve consistency in reimbursement rates among facilities. The predictability of reimbursements from year to year will be improved; thus, aiding in rate setting and stability in medical cost experiences of the system. Further, the recommendation will align all BWC fee reimbursement schedules to a prospective payment approach.

16.  Does this rule have a fiscal effect on school districts, counties, townships, or municipal corporations? No

17.  Does this rule deal with environmental protection or contain a component dealing with environmental protection as defined in R. C. 121.39? No