Briefing: What Regulations Affect the UBO? Date: 22 March 2007 Time: 0900-0950

1. Briefing: What Regulations Affect the UBO? Date: 22 March 2007 Time: 0900-0950

2. Objectives • Recognize the differences between statutes (laws), regulations, policies, directives, instructions, and manuals • Identify how, when, and which of these apply to you

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 HHS) • 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 periods

7. Statutes (Laws) v. Regulations Regulation – Bottom Line • Regulations are extremely important • Show the administration’s interpretation of a law • Example – Medicare physician referral prohibition • FIVE years for CMS to publish a final rule • Providers had no guidance on the provisions for these 5 years • Meanwhile, the providers were legally liable for abiding by the law without benefit of the administration’s interpretation

8. Statutes Third Party Reimbursement 10 USC 1095 • For any covered beneficiary, the US can collect from a third-party payer for the healthcare services rendered • This section includes MAC • The US may institute and prosecute legal proceedings against a third-party payer • Funds collected benefit the facility • They are not taken into account when determining the budget for that facility

9. Statutes Medical Services Accounts 10 USC 1079b • An MTF may charge civilians who are not covered beneficiaries (or their insurers) for emergency health care • The fees are to be used for: • Trauma consortium activities • Administrative, operating, and equipment costs • Readiness training

10. Regulations Third-Party Collections 32 CFR 220.2 • A third party payer must pay the US for healthcare services provided by an MTF to a covered beneficiary who is also a beneficiary under the third party payer’s plan • The third party payer must pay the facility • The payer cannot reimburse the beneficiary

11. Regulations The regulations also specify the rate-setting methodology UBO plan - change the regulation to allow for increased flexibility when setting rates

12. Policies Health Affairs Policies: http://www.ha.osd.mil/policies/default.cfm TMA Guidance: http://www.tricare.mil/policy/tma06pol.htm Types of documents: • Billing for newborns • Subsistence • Telephone Calls

13. Policies Polices are developed on an as-needed basis. Hurricanes Katrina and Rita • OHI issues for facilities/payers in affected areas: • Re-affirmed MSA policy of providing emergency care to civilians • Placed a hold on delinquent accounts for payers in affected states Tent Rate • DoD made changes affecting health care to civilian contractors in non-fixed deployed healthcare settings MAC Rate • OMB (White House) dictates rate publication

14. Policies Service Specific Policies • Example - Secretarial Designees • Each Military Department has its own set of rules

15. Policies Other Issuances http://www.dtic.mil/whs/directives/ • DoD Instructions (DoDI) • DoD Directives (DoDD) • Publications

16. Instructions and Manuals DoD Instruction (DoDI) • Implements a policy • Prescribes how to carry out a policy • Includes assigning responsibilities

17. Instructions and Manuals DoD Instruction (DoDI) • DoDI 6015.23 – Delivery of Healthcare at MTFs: Foreign Service Care; Third Party Collections; Beneficiary Counseling and Assistance Coordinators • Directs the Services to create UBOs • Reiterates the law stating third-party collections are above and beyond the facility’s budget • DoDI 5505.12 – Anti-Fraud Program at MTFs • Supports implementation of anti-fraud programs • Directs Military Departments to develop programs • Training and education

18. Instructions and Manuals DoD Directive (DoDD) • Broad policy document • Establishes or describes policy, programs, and organizations • Defines missions • Provides authority • Assigns responsibilities

19. Instructions and Manuals DoD Directive (DoDD) • DoD Directive 1404.10, “Emergency Essential (E-E) DoD U.S. Citizen Civilian Employees,” April 10, 1992 • E-E employees who require treatment for disease or injury sustained overseas during hostilities may receive care at no cost under the DoD MHS • The scope of care provided shall be equivalent to that received by active duty military personnel • Collect from third-party payers when feasible

20. Instructions and Manuals DoD Publications • Implements or supplements a Directive or Instruction • Provides uniform procedures for management or operational systems and disseminating administrative information • Manual • Guidance document that has procedures with examples for performing specific tasks

21. Instructions and Manuals DoD Publications • DoD 6010.15-M, "Military Treatment Facility Uniform Business Office (UBO) Manual", 11/2006 • DoD 6010.13-M, "Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities," 11/2000 • DoD 6025.18-R, "DoD Health Information Privacy Regulation," 01/2003

22. Summary • Recognize the differences between statutes (laws), regulations, policies, directives, instructions, and manuals • Identify how, when, and which of these apply to you

23. Quiz In the billing office, you should have copies of: • Statutes • Regulations • Policies • The UBO Manual • All of the above Which has the ultimate authority: • The UBO Manual • The Law • Policies