Briefing: Basic Policies

1. Briefing: Basic Policies Date: 25 March 2010 Time: 1110-1200

2. Objectives • Recognize the differences between statutes (laws), regulations, policies, directives, instructions, and manuals • Identify those policies that directly affect how you do your job

3. Statutes (Laws) v. Regulations Statutes (Laws) • Passed by the legislative branch • United States Congress • State legislatures • Provide broad basis of “do’s and don’ts” • Usually so broad, they need implementing “guidance”

4. Statutes (Laws) v. Regulations Regulations • Developed by executive branch agency responsible for that subject matter • Help clarify the intent of the law • Examples • Medicare law • Regulation promulgated by CMS (part of DHHS) • Military health care • Regulation promulgated by TMA (part of DoD)

5. Statutes (Laws) v. Regulations Regulations – Stages • Notices – Announcements to the public • MAC rates • DD Form 2569 • Proposed Rules • Implementing new law • Changing existing regulations • Comment Period

6. Statutes (Laws) v. Regulations Regulations – Stages • Final Rules • Summarize comments from proposed rules • Have the force of law • Interim Final Rules may be effective immediately with Comment Period

7. Statutes (Laws) v. Regulations

8. Policies • Developed as needed • Further interpretation of a regulation

9. HA Policies Permanent Prohibition Against Requiring Certain Injured Members to Pay for Meals Provided by Military Treatment Facilities (FY NDAA 09 – 4 Feb 2009) • MTFs must furnish meals at no cost to military members receiving inpatient or outpatient services for an injury, illness, or disease caused while in combat • Includes medical recuperation or therapy or other continuous care

10. HA Policies DHP Accounts Receivable Policy (2 May 2008) • Policy to recognize, collect, and report accounts receivable • Goal: Improve the accuracy of financial statements and prepare DHP-funded activities for audit • Compliance by each Financial Statement Reporting Entity (FSRE) required by 30 September 2008 • Delayed until 30 September 2009

11. HA Policies Policy Guidance for Provision of Medical Care Provided to DoD Civilian Employees Injured or Wounded While Forward Deployed in Support of Hostilities (24 September 07) DoD Civilians who become ill, injured, wounded while forward deployed are eligible for medical evacuation and treatment in MTFs as if they were military personnel Worker’s Compensation – employee is treated at no cost

12. HA Policies HA Policy 08-007Policy for Billing and Collections for TPCP, MSA, MAC in MTFs Billing and collection activities may be performed by MTF personnel, other Government personnel, contract personnel, or any combination of personnel  Billing and collection activities may be performed at the MTF, other Government location, contract location, or any combination of locations  MTFs are not restricted to using TPOCS or the MSA module in the Composite Health Care System

13. HA Policies HA Policy 08-007Policy for Billing and Collections for TPCP, MSA, MAC in MTFs The Services must provide management data to TMA UBO on request  The Services should implement best business practices to manage their collections programs and to meet TMA UBO reporting requirements

14. HA Policies HA Policy 08-002 Policy for Billing for Care Furnished by Military Treatment Facilities to Federal Employees for On-the-Job Injuries and for Occupational Health (8 April 2008) Bill NAF at IAR for Occupational Health and OTJ injury Do not bill DoD when furnishing Occupational Health or care for OTJ to appropriated fund DoD employees Bill all other federal agencies at IAR for Worker’s Comp Bill employees for all other care unless they are a beneficiary

15. HA Policies HA Policy 07-026 Policy for Billing Non-Department of Defense Beneficiary Newborns • DoD has a legal obligation to recover reasonable cost of health care services to non-DoD beneficiaries • MTFs are to bill for newborns of family member daughters and for certain former Service members • Bill for services from time of birth to time of discharge • Use full reimbursement rate

16. HA Policies HA Policy 06-010 HIPAA Security Compliance • Implements DHHS Security Standards • HIPAA Security charges organizations to protect e-PHI against any reasonably anticipated threats or hazards to the security and integrity of the information • Protect against any reasonably anticipated uses or disclosures that are not permitted under HIPAA • Retain compliance documentation for six years

17. HA Policies HA Policy 05-020 Policy for Cosmetic Surgery Procedures in the MHS • To accomplish wartime mission, we need specialists skilled in reconstructive cosmetic surgery • These specialists need to perform surgery regularly to keep up their skills/certification • Cosmetic procedures are authorized in direct care system under limited circumstances • Only privileged staff/residents in plastic surgery, otorhinolaryngology, ophthalmology, dermatology, oral-maxillofacial surgery may perform cosmetic surgery • 20% of their practice

18. HA Policies HA Policy 05-020 Policy for Cosmetic Surgery Procedures in the MHS • Civilians providers may only perform if they are employed full-time by MTF • Cosmetic surgery performed “space available” • May not exceed 20% of the physician’s case load • Only for TRICARE-eligible beneficiaries • Active duty must have written permission from unit commander • All patients must pay • Complications are not a covered benefit

19. HA Policies HA Policy 04-028 Termination of Subsistence Surcharge for Uniformed Services Personnel in MTFs • Do not collect daily subsistence surcharge from Active Duty or retired members hospitalized for medical care

20. HA Policies Compliance Plan Implementation Policy (28 February 2002) • “The adoption and implementation of compliance programs significantly advances the prevention of fraud, while furthering the mission of providing quality care to patients” • MTFs and other DoD-designated billing activities must establish and comply with compliance guidelines • Establish a compliance plan focused on coding and billing ethical conduct • Perform a compliance audit at least quarterly

21. HA Policies

22. DoD Issuances

23. Instructions (DoDIs) • Implement policies • Prescribe how to carry out a policy • Include assigning responsibilities

24. Instructions (DoDIs) • DoDI 6015.23 - Delivery Of Healthcare At Military Treatment Facilities: Foreign Service Care; Third-party Collection; Beneficiary Counseling And Assistance Coordinators (BCACs) • Implements policy, assigns responsibilities and prescribes procedures for • Healthcare delivery at MTFs • International military reciprocal healthcare agreements • Beneficiary Counseling and Assistance Coordinator responsibilities • Authorizes • Classification Nomenclature and Definitions Relating to Fixed and Non-fixed MTFs (DoD 6015.1-M) • Military Treatment Facility Uniform Business Office (UBO) (DoD 6010.15-M)

25. Instructions (DoDIs) • DoDI 6010.23 – DoD/DVA Health Care Resource Sharing Program • Implements policy, assigns responsibilities, and prescribes procedures to develop/operate DoD/VA Health Care Resource Sharing Agreements when it is determined that resource sharing will improve access to quality health care or increase cost-effectiveness of the health care provided by MHS and DVA to beneficiaries of both Departments • DoDI 6025.18 – Privacy of Individually Identifiable Health Information in DoD Health Care Programs • Was originally a Directive (6025.18) • Establishes policy and assigns responsibilities to implement standards for privacy of individually identifiable health information

26. Instructions (DoDIs) • DoDI 6040.40 – Military Health System Data Quality Management Control Procedures • Policy to implement the MHS Data Quality Management Control (DQMC) program • DoDI 6040.42 – Medical Encounter and Coding at Military Treatment Facilities • Implements policy, assigns responsibilities, and prescribes procedures for the documentation and coding of outpatient medical encounters in MTFs

27. Instructions (DoDIs) • DoDI 5505.12 – Anti-Fraud Program at Military Treatment Facilities (MTFs) • Implements policy, assigns responsibilities, and prescribes procedures to prevent, detect, report, and evaluate suspected fraud by contracted civilian healthcare providers at all DoD MTFs

28. Instructions (DoDIs) • DoDI 1000.24 – Confiscation of Fraudulent Identification (ID) Cards at Military Treatment Facilities • MTFs must have an ID card fraud policy program • MTFs have a duty to identify and eliminate eligibility fraud • Checking eligibility in DEERS • MTF must seek recovery of costs for any medical care furnished to anyone found to be ineligible

29. Instructions (DoDIs) • DoDI 1000.24 – Common situations that affect eligibility: • Separation from the Service • Eligible children reach the age of 21 (except for certain situations) • Divorce from a sponsor (unless the spouse meets certain eligibility requirements) • Sponsors must report, within 30 days, any change in their own status, or that of a family member, that affects eligibility for medical care. • Otherwise, they run the risk of being financially responsible for any medical care provided

30. Instructions (DoDIs) • DoDI 1000.24 • MTFs should ensure that a responsible individual reviews the daily CHCS report listing individuals who received care and are not in DEERS • MTFs are not the final decision-makers on beneficiary eligibility for care • Only Service Personnel offices can make final determinations of beneficiary eligibility

31. DoD Directives (DoDDs) • Broad policy documents • Establish or describe policy, programs, and organizations • Define missions • Provide authority • Assign responsibilities

32. DoD Directives (DoDDs) • DoDD 5400.11 – DoD Privacy Program • DoDD 6010.04 – Healthcare for Uniformed Services Members and Beneficiaries • The Uniformed Services shall operate medical and dental treatment facilities in accordance with applicable law, regulation, and policy • The CHAMPUS/TRICARE health care entitlement shall be provided consistent with current law • Health care beneficiaries shall be provided access to military treatment facilities

33. DoD Directives (DoDDs) • DoDD 6025.13 – Medical Quality Assurance (MQA) in the Military Health System (MHS) • Establishes DoD policy on issues related to MQA programs and activities • DoDD 6040.41 – Medical Records Retention and Coding at Military Treatment Facilities • Establishes policy and assigns responsibilities for administering medical records retention and encounter coding • Provides medical records retention and coding reporting • Provides guidance for medical records retention and encounter coding at MTFs

34. DoD Publications • Implement or supplement a Directive or Instruction • Provide uniform procedures for management or operational systems and disseminating administrative information • Manual • Guidance document that has procedures with examples for performing specific tasks

35. DoD Publications • DoD 6010.15-M • UBO Manual • DoD 6010.13-M • MEPRS Manual • DoD 7000.14-R • DoD Financial Management Regulation

36. DoD Publications • DoD 5400.11-R • DoD Privacy Program • Prescribes uniform procedures for implementation of the DoD Privacy Program • DoD 6025.18-R • DoD Health Information Privacy Regulation • Outlines uses and disclosures of protected health information  • DoD 8580.02-R • DoD Health Information Security Regulation • Implements HIPAA

37. DoD Publications • DoD  6015.1-M • Glossary of Healthcare Terminology   • Uniform glossary of healthcare terminology for use throughout the Department of Defense • DoD  6025.13-R • Military Health System Clinical Quality Assurance Program Regulation • Identifies the various components comprising DoD’s efforts to ensure that beneficiaries receive quality care

38. Summary • Recognize the differences between statutes (laws), regulations, policies, directives, instructions, and manuals • Identify those policies that directly affect how you do your job

39. Quiz • True or False: • Congress passes HA Policies • A policy is more important than a statute • Cosmetic surgery is a free covered benefit for all TRICARE beneficiaries