Medicaid Disallows Reimbursement, Requires Reporting for Provider Preventable Conditions

Starting  July 1, 2013, the Washington Medicaid program will not pay a provider for the health care costs of treating conditions that the provider could have prevented.  The rule, WAC 182-502-0022, contains a long list of such conditions and adds a few more acronyms to health care speak, including:

(1) PPC – provider preventable conditions that include hospital and non-hospital acquired conditions;

(2) OPPC – other provider preventable conditions that are a PPC subset of conditions identified in WAC 246-302-030, and;

(3) HCAC – health care acquired conditions that are also a PPC subset occurring in an inpatient hospital setting.

Providers, including inpatient hospitals, must report any PPC to the Health Care Authority even if there is no intent to bill for services related to the PPC.  Health care professionals or designees responsible for or associated with a PPC involving a Medicaid patient must notify the Health Care Authority within forty-five (45) calendar days of confirming the PPC.

A similar reporting requirement applies to hospitals for OPPC.  And, of course, Medicaid patients are not liable for payment of an item related to a HCAC or an OPPC and must not be billed for any item or service related to a PPC.

For information about this new rule or Medicaid reimbursements please contact Greg Montgomery.

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