[Federal Register Volume 60, Number 148 (Wednesday, August 2, 1995)]
[Proposed Rules]
[Pages 39285-39287]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-18961]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 220
Collection From Third Party Payers of Reasonable Costs of
Healthcare Services
AGENCY: Office of the Secretary, DoD.
ACTION: Proposed rule.
-----------------------------------------------------------------------
SUMMARY: This proposed rule would establish a new rule under the Third
Party Collection program for determining the reasonable costs of health
care services provided by facilities of the uniformed services in cases
in which care is provided under TRICARE Resource Sharing Agreements.
For purposes of the Third Party Collection program such services will
be treated the same as other services provided by facilities of the
uniformed services. The proposed rule also lowers the high cost
ancillary threshold value from $60 to $25 for patients that come to the
uniformed services facility for ancillary services requested by a
source other than a uniformed services facility provider. The
reasonable costs of such services will be accumulated on a daily basis.
DATES: Written comments on this proposed rule must be received on or
before October 2, 1995.
ADDRESSES: LCDR Pat Kelly, Office of the Assistant Secretary of Defense
[[Page 39286]]
(Health Affairs), Health Services Operations and Readiness, Pentagon
Room 3E343, Washington, D.C. 20301-1200.
FOR FURTHER INFORMATION CONTACT:
LCDR Patrick Kelly, (703) 756-8910.
SUPPLEMENTARY INFORMATION: Currently, the Third Party Collection
program regulation includes a special rule for Partnership Program
providers. The Partnership Program allows civilian health care
providers authorized to provide care under the CHAMPUS program to
provide services to CHAMPUS beneficiaries in military hospitals and to
receive payment from the CHAMPUS program. Pursuant to CHAMPUS payment
rules, CHAMPUS is always the secondary payer to other health insurance
plans; Thus, CHAMPUS may not make payment to the Partnership Program
provider in cases in which the beneficiary has other health insurance.
To accommodate this CHAMPUS requirement, the third Party Collection
program currently excludes Partnership Program provider services from
the military hospital claims. Thus, for example, for inpatient hospital
care, the Third Party Payer now receives two claims, one from the
military facility for the hospital and ancillary costs, and a separate
claim from the provider for the professional services.
The current practice has produced some confusion in that it is a
departure from the normal procedure for claims arising from care
provided by military hospitals. In addition, because the Partnership
Program providers function independently from the military hospital's
management system, there are no DoD standards that govern the amounts
claimed by various Partnership Program providers.
DoD is now proceeding with implementation of a major managed care
program, called TRICARE, in its military medical treatment facilities
and CHAMPUS. Under TRICARE, regional managed care support contractors
will work with military treatment facilities on a wide range of managed
care activities. Among the activities of the managed care contractors
is the Resource Sharing Program. Under this program, the contractor
makes agreements with military hospitals in the region under which the
contractor will supply personnel and other resources in order to allow
the facility to increase the services it can make available to DoD
health care beneficiaries. The TRICARE program is now the subject of a
separate rulemaking proceeding, which will result in comprehensive
regulations codified at 32 CFR 199.17.
TRICARE Resource Sharing Agreements are similar to Partnership
Program payment arrangements in that both result in civilian providers
coming into the military facility and providing care in that facility.
However, a significant difference exists in the method of payment.
Under the Partnership Program, payment is on a fee-for-service basis
under the normal operation of the CHAMPUS program. Under Resource
Sharing, the method of payment may be on a salary basis or other
arrangement made by the managed care support contractor. Under the
Partnership Program, the CHAMPUS second payer requirement applies.
Under Resource Sharing Agreements, the overall managed care contract
separates the financing from the normal CHAMPUS payment rules and
allows for special payment rules.
Based on this, we are establishing a special rule for Resource
Sharing Agreements. Or, more accurately, we are establishing the normal
rule for Resource Sharing Agreements. That is to say that care provided
in whole or in part through TRICARE Resource Sharing Agreements will be
handled for purposes of third party billings just like all other
services provided in the military facility, and will be billed at the
same rates. The special rule applicable to the Partnership Program
providers, under which two claims are made to the third party payer,
will not apply under TRICARE Resource Sharing Agreements. As a result,
care provided in military facilities will be billed to third party
payers in the same manner and same amount, regardless of whether the
professional services were provided by a military physician or Resource
Sharing Agreement provider.
The TRICARE program is being phased in region-by-region throughout
the United States. As it takes hold, we expect the Partnership Program
to be phased out and be replaced by TRICARE Resource Sharing
Agreements. Thus, in several years, the special Partnerhship Program
rule will no longer be needed, and the simpler, single-claim rule for
TRICARE Resource Sharing Agreements will apply. We view this as both a
simplification and an improvement in the Third Party Collection
program.
With respect to regulatory procedures, this proposed rule is not a
significant regulatory action under Executive Order 12866, nor does it
significantly affect a substantial number of small entities under the
Regulatory Flexibility Act, nor impose new information collection
requirements under the Paperwork Reduction Act. This is a proposed
rule. All public comments are invited. We expect to proceed with
promulgation of a final rule within approximately 60 days after close
of the comment period.
List of Subjects in 32 CFR Part 220
Claims, Health care, Health insurance.
For the reasons stated in the preamble, 32 CFR part 220 is proposed
to be amended as follows:
PART 220--COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE COSTS OF
HEALTHCARE SERVICES
1. The authority citation for part 220 continues to read as
follows:
Authority: 5 U.S.C 301; 10 U.S.C. 1095.
2. Section 220.8 is amended by revising paragraphs (h) and (k) to
read as follows:
Sec. 220.8 Reasonable costs.
* * * * *
(h) Special rule for certain ancillary services ordered by outside
providers and provided by a facility of the Uniformed Services. If a
Uniformed Services facility provides certain ancillary services,
prescription drugs or other procedures requested by a source other than
a Uniformed Services facility and are not incident to any outpatient
visit or inpatient services, the reasonable cost will not be based on
the usual DRG or per visit rate. Rather, a separate standard rate shall
be established based on the accumulated cost of the particular
services, drugs, or procedures provided during one day. The billing
threshold shall be published annually. For fiscal year 1996 that
threshold limit shall be $25. The reasonable cost for the services,
drugs or procedures to which this special rule applies shall be
calculated and made available to the public annually.
* * * * *
(k) Special rules for TRICARE Resource Sharing Agreements and
Partnership Program providers.
(1) In general. This paragraph (k) establishes special Third Party
Collection program rules for TRICARE Resource Sharing Agreements and
Partnership Program providers.
(i) TRICARE Resource Sharing Agreements are agreements under the
authority of 10 U.S.C. 1096 and 1097 between uniformed services
treatment facilities and TRICARE managed care support contractors under
which the TRICARE managed care support contractor provides personnel
and other resources to the uniformed services treatment facility
concerned in order to help the facility increase the availability of
health care services for beneficiaries. TRICARE is the managed care
program authorized by 10 U.S.C. 1097 (and
[[Page 39287]]
several other statutory provisions) and established by regulation at 32
CFR 199.17.
(ii) Partnership Program providers provide services in facilities
of the uniformed services under the authority of 10 U.S.C. 1096 and the
CHAMPUS program. They are similar to providers providing services under
TRICARE Resource Sharing Agreements, except that payment arrangements
are different. Those functioning under TRICARE Resource Sharing
Agreements are under special payment arrangements with the TRICARE
managed care contractor; those under the Partnership Program file
claims under the standard CHAMPUS program on a fee-for-service basis.
(2) Special rule for TRICARE Resource Sharing Agreements. Services
provided in facilities of the uniformed services in whole or in part
through personnel or other resources supplied under a TRICARE Resource
Sharing Agreement are considered for purposes of this Part as services
provided by the facility of the uniformed services. Thus, third party
payers will receive a claim for such services in the same manner and
for the same costs as any similar services provided by a facility of
the uniformed services.
(3) Special rule for Partnership Program providers. For inpatient
services for which the professional provider services were provided by
a Partnership Program provider, the professional charges component of
the total inpatient DRG rate will be deleted from the claim from the
facility of the uniformed services. The third party payer will receive
a separate claim for professional services directly from the individual
health care provider. The same is true for the professional services
provided on an outpatient basis under the Partnership Program. Claims
from Partnership Program providers are not covered by 10 U.S.C. 1095 or
this part, but are governed by statutory and regulatory requirements of
the CHAMPUS program.
* * * * *
July 28, 1995.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 95-18961 Filed 8-1-95; 8:45 am]
BILLING CODE 5000-04-M
