[Federal Register Volume 60, Number 229 (Wednesday, November 29, 1995)]
[Notices]
[Pages 61450-61452]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-29043]
[[Page 61449]]
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Part VII
Office of Management and Budget
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Cost of Hospital and Medical Care and Treatment Furnished by the United
States; Certain Rates Regarding Recovery From Tortiously Liable Third
Persons; Notice
Federal Register / Vol. 60, No. 229 / Wednesday, November 29, 1995 /
Notices
[[Page 61450]]
OFFICE OF MANAGEMENT AND BUDGET
Cost of Hospital and Medical Care and Treatment Furnished by the
United States; Certain Rates Regarding Recovery From Tortiously Liable
Third Persons
By virtue of the authority vested in the President by Section 2(a)
of P.L. 87-693 (76 Stat. 593; 42 U.S. C. 2652), and delegated to the
Director of the Office of Management and Budget by Executive Order No.
11541 of July 1, 1970 (35 FR 10737), the three sets of rates outlined
below are hereby established. These rates are for use in connection
with the recovery, from tortiously liable third persons, of the cost of
hospital and medical care and treatment furnished by the United States
(Part 43, Chapter I, Title 28, Code of Federal Regulations) through
three separate Federal agencies. The rates have been established in
accordance with the requirements of OMB Circular A-25, requiring
reimbursement of the full cost of all services provided. The rates are
established as follows:
(1) Department of Defense. The FY 1996 inpatient rates are based on
the cost per Diagnostic Related Group (DRG), which is the inpatient
full reimbursement rate per hospital discharge, weighted to reflect the
intensity of the principal diagnosis involved. The average cost per
Relative Weighted Product (RWP) for large urban, other urban/rural and
overseas facilities will be published annually as an inpatient
standardized amount.
The adjusted standardized amounts (ASA) per Relative Weighted
Product (RWP) for use in the Direct Care System will be comparable to
procedures utilized by Health Care Financing Administration (HCFA) and
the Civilian Health and Medical Program for the Uniformed Services
(CHAMPUS). These expenses will include all direct care expenses. The
average cost per relative weighted product for large urban, other
urban/rural and overseas facilities will be published annually as an
inpatient standardized amount and will include the cost of inpatient
professional services. The DRG rates will apply to reimbursement from
all sources. A relative weight for each DRG using the standardized
amount will be the same as the DRG weights published annually for
hospital reimbursement rates under the Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS) pursuant to 32 CFR
199.14(a)(1) which includes adjustments for outliers, area wages, and
indirect medical education.
(2) Department of Health and Human Services. The sum of obligations
for each cost center providing medical service is broken down into
amounts attributable to inpatient care on the basis of the proportion
of staff devoted to each cost center. Total inpatient costs and
outpatient costs thus determined are divided by the relevant workload
statistic (inpatient day, outpatient visit) to produce the inpatient
and outpatient rates. In calculation of the rates, the Department's
unfunded retirement liability cost and capital and equipment
depreciation cost were incorporated to conform to requirements set
forth in OMB Circular A-25. In addition, each cost center's obligations
include all costs for accounts, such as Medicare and Medicaid
collections and Contract Health funds used to support direct program
operation. Inclusion of these funds yields a more accurate indication
of the cost of care in HHS facilities.
(3) Department of Veterans Affairs. The actual costs and per diem
rates by type of care the previous year are added to the facility
overhead costs and then adjusted by the budgeted percentage change for
the current year and the budget year to compute the base rate for the
budget year. The base rate is then adjusted by the estimated cost for
depreciation of buildings and equipment, central office overhead,
Government employee retirement and disability charges, and return on
fixed assets (interest on capital for land, buildings and equipment
(net book value)), to compute the budget year tortiously liable
reimbursement rates. Also shown for inpatient per diem rates are
breakdowns into three cost components: Physician; Ancillary; and
Nursing, Room and Board. As with the total per diem rates, these
breakdowns are calculated from actual data by type of care for the
previous year.
These rates represent the reasonable cost of hospital, nursing
home, medical, surgical, or dental care and treatment (including
prostheses and medical appliances) furnished or to be furnished by the
United States in Federal hospitals, nursing homes, and outpatient
clinics administered by the Department of Defense, the Department of
Veterans Affairs and the Department of Health and Human Services.
For such care and treatment furnished at the expense of the United
States in a facility not operated by the United States, the rates shall
be the amounts expended for such care and treatment.
For the Department of Defense, effective October 1, 1995 and
thereafter:
I. Inpatient Rates (Per Inpatient Day)\1\
Full
reimbursement
rate
A. Burn Center.......................................... $3,794
B. Surgical Care Services (Cosmetic Surgery)............ 1,567
C. All Other Inpatient Services (Based on Diagnosis Related Groups (DRG)
Charges)
1. FY 1996 Direct Care Inpatient Reimbursement Rates (Adjusted
Standard)
Full cost
Large Urban............................................. $4,713
Other Urban/Rural....................................... 4,745
Overseas................................................ 6,038
2. Overview
The FY 1996 inpatient rates are based on the cost per DRG which
is the inpatient full reimbursement rate per hospital discharge,
weighed to reflect the intensity of the principal diagnosis
involved. The average costs per Relative Weighted Product (RWP) for
large urban, other urban/rural and overseas facilities will be
published annually as an inpatient standardized amount. (See item 1
above). A ``relative weighted product'' for each DRG case to apply
to the standardized amount will be determined from DRG weights
published annually for hospital reimbursement rates under the
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS) pursuant to 32 CFR 199.14(a)(1) with adjustments for
outliers. Standardized amounts will be adjusted for area wage
differences and indirect medical education. An example of how to
apply DoD costs to a DRG standardized weight to arrive at DoD costs
is contained in part 3 of Section I.C., below.
3. Example of Adjusted Standardized Amounts for Procedures
Performed
Large Urban Area--Example
a. The cost to be recovered is DoD's cost for medical services
provided in a large urban area. Billings will be at the third party
rate.
b. DRG 020: Nervous System infection except viral meningitis.
Relative Weighed Product for an inlier case is the CHAMPUS weight of
2,0327.
c. The DoD adjusted standardized amount to be recovered is
$4,713 (i.e., the third party rate as shown in the table).
d. DoD cost to be recovered at a non-teaching hospital with area
wage index of 1.0 is the RWP factor (2,0327) in item 3.b., above,
times the amount ($4,713) in 3.c., above.
Cost to be recovered is $9,580.
II. Outpatient Rates\1\
Full
Code Clinical services reimbursement
rate
A. Medical Care
BAA Internal Medicine........... $163
BAB Allergy..................... 56
BAC Cardiology.................. 116
BAE Diabetes.................... 70
BAF Endocrinology............... 152
[[Page 61451]]
BAG Gastroenterology............ 190
BAH Hematology.................. 269
BAI Hypertension................ 60
BAJ Nephrology.................. 230
BAK Neurology................... 177
BAL Nutrition................... 51
BAM Oncology.................... 157
BAN Pulmonary Disease........... 205
BAO Rheumatology................ 147
BAP Dermatology................. 100
BAQ Infectious Disease.......... 139
BAR Physical Medicine........... 132
B. Surgical Care
BBA General Surgery............. 193
BBB Cardiovascular/Thoracic 183
Surgery.
BBC Neurosurgery................ 228
BBD Ophthalmology............... 131
BBE Organ Transplant............ 262
BBF Otolaryngology.............. 150
BBG Plastic Surgery............. 170
BBH Proctology.................. 159
BBI Urology..................... 174
BBJ Pediatric Surgery........... 125
C. Obstetrical and Gynecological (OB-GYN)
BCA Family Planning............. 87
BCB Gynecology.................. 118
BCC Obstetrics.................. 113
D. Pediatric Care
BDA Pediatric................... 88
BDB Adolescent.................. 86
BDC Well Baby................... 64
E. Orthopaedic Care
BEA Orthopaedic................. 163
BEB Cast Clinic................. 69
BEC Hand Surgery................ 69
BEE Orthopaedic Appliance....... 112
BEF Podiatry.................... 79
BEZ Chiropractic Clinic......... 49
F. Psychiatric and/or Mental Health Care
BFA Psychiatry.................. 165
BFB Psychology.................. 135
BFC Child Guidance.............. 56
BFD Mental Health............... 119
BFE Social Work................. 129
BFF Substance Abuse 98
Rehabilitation.
G. Primary Medical Care
BGA Family Practice............. 105
BHA Primary Care................ 102
BHB Medical Examination......... 93
BHC Optometry................... 71
BHD Audiology Clinic............ 57
BHE Speech Pathology............ 88
BHF Community Health............ 80
BHG Occupational Health......... 84
BHI Immediate Care Clinic....... 139
H. Emergency Medical Care
BIA Emergency Care Clinic 163...
I. Flight Medicine Clinic
BJA Flight Medicine............. 151
J. Underseas Medicine Care
BKA Underseas Medicine Clinic 65
K. Rehabilitative Services
BLA Physical Therapy............ 49
BLB Occupational Therapy........ 96
BLC Neuromuscular Skeletal 37
Screening.
L. Same Day Surgery 767
III. Other Rates and Charges
Full
reimbursement
rate
A. Immunizations........................................ $18
B. Hyperbaric Services:
1-60 minutes.......................................... 233
61-120 minutes........................................ 452
121-180 minutes....................................... 671
181-240 minutes....................................... 889
Each Additional Hour (Note: Charges may be prorated
based on usage)...................................... 233
C. Family Member Rate (Formerly Military Dependents
Rate).................................................. 9.70
For the Department of Health and Human Services, Indian Health
Service, effective October 1, 1995 and thereafter:
HHS
Hospital Care Inpatient Day:
General Medical Care......................................... $2,018
Outpatient Medical Treatment:
Outpatient Visit............................................. 195
For the Department of Veterans' Affairs effective October 1,
1995 and thereafter:
Hospital Care, rates per inpatient day
General Medicine............................................... $966
Physician.................................................... 116
Ancillary.................................................... 252
Nursing, Room and Board...................................... 598
Surgery........................................................ 1,576
Physician.................................................... 174
Ancillary.................................................... 478
Nursing, Room and Board...................................... 924
General Psychiatry............................................. 458
Physician.................................................... 43
Ancillary.................................................... 72
Nursing, Room and Board...................................... 343
Intermediate Medicine.......................................... 337
Physician.................................................... 17
Ancillary.................................................... 49
Nursing, Room and Board...................................... 271
Neurology...................................................... 847
Physician.................................................... 124
Ancillary.................................................... 224
Nursing, Room and Board...................................... 499
Rehabilitation Medicine........................................ 712
Physician.................................................... 81
Ancillary.................................................... 218
Nursing, Room and Board...................................... 413
Blind Rehabilitation........................................... 859
Physician.................................................... 69
Ancillary.................................................... 427
Nursing, Room and Board...................................... 363
Spinal Cord Injury............................................. 855
Physician.................................................... 106
Ancillary.................................................... 215
Nursing, Room and Board...................................... 534
Substance Abuse (Alcohol and Drug Treatment)................. 295
Physician.................................................... 28
Ancillary.................................................... 68
Nursing, Room and Board...................................... 199
Nursing Home Care, rates per day
Nursing Home Care............................................ 266
Physician.................................................... 8
Ancillary.................................................... 36
Nursing, Room and Board...................................... 222
Outpatient Medical and Dental Treatment
Outpatient Visit............................................... 205
Emergency Dental Outpatient Visit............................ 104
Prescription Filled.......................................... 20
Notes
1. Pursuant to the provisions of 10 U.S.C. 109, the inpatient
Diagnosis Related Groups are 96 percent hospital and 4 percent
professional fee. The outpatient per visit percentages are 58
percent hospital, 29 percent ancillary and 13 percent professional.
2. The Medical Expense and Performance Reporting System (MEPRS)
code is a three digit code which defines the summary account and the
subaccount within a functional category in the DoD medical system.
An example of this hierarchical arrangement is as follows:
Outpatient Care (Functional Category) MEPRS Code
Medical Care (Summary Account).............. BA
Internal Medicine (Subaccount).............. BAA
MEPRS codes are used to ensure that consistent expense and
operating performance data is reported in the DoD military medical
system.
For the period beginning October 1, 1995, the rates prescribed
herein superseded those established by the Director of the Office of
[[Page 61452]]
Management and Budget October 24, 1994 (59 FR 53492).
Alice M. Rivlin,
Director, Office of Management and Budget.
[FR Doc. 95-29043 Filed 11-28-95; 8:45 am]
BILLING CODE 3110-01-P
