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Resources for Hospital Providers

Resources for Hospital Providers

New! Wisconsin Hospital CARES Funding Application and Initial Allocation Amount

Hospital Claim Payments and Access Payments

ForwardHealth prices most inpatient hospital claims, Medicare crossover claims, and HMO encounters with dates of discharge or "To" dates of service (DOS) on and after January 1, 2017, using the All Patient Refined Diagnosis Related Group (APR DRG) classification system. ForwardHealth prices most outpatient hospital services using the Enhanced Ambulatory Patient Groups (EAPG) classification system. Rehabilitation and psychiatric hospitals are reimbursed per diem for inpatient services, but they also receive EAPG-classified payments for outpatient services.

Hospital rates and weights for DRG and EAPG and per diem rates are available on the Hospital Rates and Weights Portal page. (Note: This page was formerly titled Inpatient & Outpatient Hospital Rates and Inpatient Hospital Weights.) The Hospital Rates and Weights Portal page also contains outpatient per-visit rates for other payers such as county jails.

For SFY 2022, the Fee-For-Service access payment funding pool amounts are as follows:

  • Acute care, children's, long term acute, and rehabilitation hospitals:
    • Inpatient: $103,492,419
    • Outpatient: $84,675,616
  • Critical access hospital:
    • Inpatient: $1,546,798
    • Outpatient: $1,265,562
The specific claim add-on amounts can be found on the Inpatient and Outpatient hospital rate listing on the Hospital Rates and Weights Page.

Disproportionate Share Hospital (DSH) Program

As authorized by §9230 of the Medicaid Hospital State Plan Hospital Attachment 4.19-A, hospitals located in Wisconsin may receive a supplemental DSH payment for service a disproportionate share of low-income patients. To be eligible for these DSH payments, hospitals must meet minimum federal requirements for Medicaid DSH payments as specified in §1923(b) and (d) of the Social Security Act (42 U.S.C. 1396r-4(b) and (d))] as well as the qualifying criteria outlined under §9232.

Payments are calculated and distributed on a State Fiscal Year (SFY) basis. Payments are audited approximately four years after distribution.

SFY 2022 DSH Updates Payments

SFY 2022 Disproportionate Share Hospital (DSH) quarterly payment amounts for each hospital provider can be found here.

SFY 2023 DSH Updates Provider Educational Session

On February 2, 2022, the Department of Health Services provided an educational session on the DSH audit regarding state fiscal year (SFY) 2019 payments and the DSH payment limit calculation for SFY 2023. A recording of the session can be streamed here.

The session slides can be downloaded here.

SFY 2020 Surveys

Surveys capturing SFY20 data are used for the SFY23 DSH payment limit calculation which, in turn, informs the SFY23 DSH payments. These were distributed to providers in January 2022, and as a reminder, these surveys are due to Myers and Stauffer on April 1, 2022.

SFY 2019 DSH Audit Updates SFY19 Surveys

Surveys capturing SFY19 data are used to audit the SFY19 DSH payments. These surveys were already completed and received by providers in 2021.

Rural Critical Care Supplement Program

As authorized by §9300 of the Medicaid Hospital State Plan Hospital Attachment 4.19-A, critical access hospitals located in Wisconsin may receive a supplemental critical care supplemental payment. To be eligible for these payments, hospitals must not qualify for any disproportionate share hospital (DSH) payments and must meet the criteria outlined under §9311.

SFY 2022 Updates Payments

A listing of critical care supplement (CCS) payment amounts for each hospital provider can be found here.

Wisconsin Medicaid Hospital State Plans

Wisconsin regularly files both an Inpatient Hospital State Plan and an Outpatient Hospital State Plan with the federal Centers for Medicare and Medicaid Services. The state plans detail the pricing methodology for hospitals serving ForwardHealth members. When these documents are updated, the outdated state plans are archived for reference purposes.

Wisconsin Current Wis. Medicaid Inpatient Hospital State Plan

Current Wis. Medicaid Outpatient Hospital State Plan.

Current System Information

Current version information and installation dates for the 3M Grouper Plus System, the APR DRG Grouper, and the EAPG grouper can be found on the Hospital Rates and Weights Portal page.

Wisconsin Medicaid Hospital Quality Pay-for-Performance (P4P) Program

The goal of the Medicaid Hospital Quality P4P program is to promote and recognize high quality patient care provided at hospitals throughout Wisconsin. DHS believes that through high quality patient care, it will be possible to increase positive health outcomes and improve the lives of all Wisconsin residents. Therefore, this program is an integral part of the overall quality initiative at the Department of Health Services (DHS). DHS encourages all hospitals to actively participate in the P4P program by working toward meeting the performance targets set for each measure, as well as maintain high performance in all areas, including those not covered by this program.

Measurement Year (MY) 2020 Updates

DHS announced at the Medicaid Advisory Hospital Group (MAHG) meeting on October 7, 2021, that MY 2020 P4P incentives were put on hold to evaluate the impact of the COVID-19 pandemic and determine appropriate next steps. The following summarizes the resulting P4P direction:

  • Assessment P4P Program: DHS proceeded with this incentive program. Payments were issued by December 31, 2021.
  • Hospital PPR Withhold Program: DHS did not proceed with this program. In lieu of the final MY 2020 payment, any amounts withheld from claims with 2020 dates of service and submitted through November 5, 2021, will be paid back as a lump sum to hospitals. No funding was withheld from claims submitted after November 5, 2021. Final performance reports were still posted to the ForwardHealth Portal by December 31, 2021. If you require supporting documentation, please contact DHSDMSBRS@dhs.wisconsin.gov

Measurement Year (MY) 2020 Updates

DHS continues to monitor and evaluate the impact of COVID-19 on the Medicaid Hospital Quality P4P program. Updates will be communicated via email as well as posted here.

  • Health Information Exchange (HIE) Program: Results are delayed and will be communicated to hospitals by mid-March 2022. Final payout expected end of March.
  • Assessment P4P Program: CheckPoint data included in this program will be cutoff on June 30, 2022. Performance results will be communicated to hospitals in September 2022, with final payout by October 30, 2022.
  • Hospital PPR Withhold Program: Claims with dates of service during calendar year 2021 that are submitted prior to June 30, 2022, will be included in the calculation of performance results for MY 2021. Performance results will be communicated to hospitals in September 2022, with final payout by October 30, 2022.

Pay-for-Performance Guides

Wisconsin offers incentive payments to Wisconsin acute care, children’s, and rehabilitation hospitals that meet certain performance targets. The following links are to Hospital Pay-for-Performance (P4P) Guides that were updated in their entirety on the dates listed. Historic P4P Guides can be found here.

Potentially Preventable Readmissions

Information on Potentially Preventable Readmissions (PPRs) was presented at the January 10th 2017 and March 21st 2017 Medicaid Hospital Advisory Group (MAHG) meetings. Please see the materials in the MAHG section below for information regarding PPRs

Additional information on PPRs is also included in the Measurement Year 2018 P4P guide and presentation in the section above.

Medicaid Advisory Hospital Group Meetings

The Department of Health Services Division of Medicaid Services holds regular meetings with hospital providers to provide updates and gather feedback. Materials from previous meetings can be found below.

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