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Resources for Hospital Providers

Resources for Hospital Providers

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 2020, the Fee-For-Service access payment funding pool amounts are as follows:

  • Acute care, children's, long term acute, and rehabilitation hospitals:
    • Inpatient: $112,732,814
    • Outpatient: $92,235,939
  • Critical access hospital:
    • Inpatient: $1,601,016
    • Outpatient: $1,309,922
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 Program

A listing of Disproportionate Share Hospital (DSH) quarterly payment amounts for each hospital provider can be found here.

On March 6, 2019, the Department of Health Services provided an educational session on the DSH audit related to state fiscal year (SFY) 2016 payments. A recording of the session can be streamed here.

The session slides can be downloaded 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 When these documents are updated, the outdated state plans are archived for reference purposes.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 Medicaid Inpatient Hospital State Plan – March 1, 2019

Wisconsin Medicaid Outpatient Hospital State Plan – March 1, 2019

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 Program

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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