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DOD/DODOASHA RIN: 0720-AB68 Publication ID: Fall 2019 
Title: Collection From Third-Party Payers of Reasonable Charges for Healthcare Services 
Abstract:

This final rule will update current regulations in order to expand the Department of Defense’s authority to compute reasonable charges for inpatient and ambulatory (outpatient) institutional resources and also for pharmaceuticals, durable medical equipment (DME), supplies, immunizations, injections, or other medications administered or furnished by DoD military treatment facilities (MTFs) under their three existing healthcare cost recovery programs--Third-Party Collections, Medical Services Accounts, and Medical Affirmative Claims. Specifically, the rule will update the reasonable charges methodologies for inpatient and ambulatory institutional billing to allow for the use of Itemized Resource Utilization (IRU) based rates--developed from the cost to provide inpatient and ambulatory institutional healthcare resources and/or publicly available charge data sources--in addition to current bundled prospective reimbursement approaches of diagnostic-related group (DRG), ambulatory payment classification (APC), ambulatory surgery center (ASC), and ambulatory procedure visit (APV) based rates. It will also revise the reasonable charges methodology for pharmaceuticals, DME, supplies, immunizations, injections or medication administered to allow for their calculation using either Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) prevailing rates or IRU based rates--developed from the cost to provide these health care items and resources and/or publically available charge data sources--regardless of whether CHAMPUS prevailing rates are available. These additional IRU methodologies--authorized by 10 U.S.C. 1095(f) and 1097b(b) and endorsed by section 1079b--will implement an itemized rate and reasonable charges structure that: improves collections and operation of DoD’s healthcare cost recovery programs by ensuring MTFs receive appropriate reimbursement for institutional healthcare resources as well as for pharmaceuticals, DME, supplies, immunizations, injections, or medication provided or administered; is more consistent with civilian health insurance industry practice; and allows the Military Health System (MHS) to accommodate new value-based provider reimbursement methodologies (e.g., pay for performance, bundled payments, shared savings/accountable care organizations) emerging from ongoing healthcare reform initiatives, including the Patient Protection and Affordable Care Act (PPACA), Public Law 111-148, 42 U.S.C. 18001 et seq. (2010). The final rule will also replace "hospital" with "institutional" throughout most of the regulation to align it with civilian health insurance industry terminology and better promote identification and separate billing of institutional and professional services as required by 32 CFR 220.8(b).

 
Agency: Department of Defense(DOD)  Priority: Substantive, Nonsignificant 
RIN Status: Previously published in the Unified Agenda Agenda Stage of Rulemaking: Final Rule Stage 
Major: No  Unfunded Mandates: No 
EO 13771 Designation: Not subject to, not significant 
CFR Citation: 32 CFR 220   
Legal Authority: 5 U.S.C. 301    10 U.S.C. 1095(f)    10 U.S.C. 1079b    10 U.S.C. 1097b(b)   
Legal Deadline:  None
Timetable:
Action Date FR Cite
NPRM  12/18/2018  83 FR 64768   
NPRM Comment Period End  02/19/2019 
Final Action  02/00/2020 
Regulatory Flexibility Analysis Required: No  Government Levels Affected: None 
Small Entities Affected: No  Federalism: No 
Included in the Regulatory Plan: No 
RIN Data Printed in the FR: No 
Agency Contact:
DeLisa Prater
DHA Uniform Business Office Program Manager
Department of Defense
Office of Assistant Secretary for Health Affairs
Agency Uniform Business Office, Defense Health Headquarters, 7700 Arlington Boulevard,
Falls Church, VA 22042
Phone:703 681-6757
Email: delisa.e.prater.civ@mail.mil