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Billing and Reimbursement Issues Discussion

Billing and Reimbursement Issues Discussion. Authorities. Program Authority: Public Law 97-174 Public Law 107-314 Title 38, Section 8111 Title 10, Section 1104 DoD Instruction 6010.23 Department of Defense and Department of Veterans Affairs Health Care Resource Sharing Program

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Billing and Reimbursement Issues Discussion

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  1. Billing and ReimbursementIssues Discussion

  2. Authorities • Program Authority: • Public Law 97-174 • Public Law 107-314 • Title 38, Section 8111 • Title 10, Section 1104 • DoD Instruction 6010.23 • Department of Defense and Department of Veterans Affairs Health Care Resource Sharing Program • VHA Handbook 1660.4 - VA-DOD Health Care Resources Sharing • In addition to other policy directives and instructions **DoD Instruction 4000.19, Interservice and Intergovernmental Support is NOT to be used…….

  3. General Principles for Reimbursement • Methodology will be agreed to by both Departments • Provide flexibility to take into account local conditions and actual costs (actual = incremental) • Funds will be credited to the providing facility • Per NDAA for FY 2003, rates will be standardized; waivers were allowed • MOU states no GME reimbursement for direct sharing agreements • JVs have choice to use or not use standard rates • Standardized methodology does not apply to TRICARE Network contracts

  4. General Principles for Reimbursement • Waivers allowed if rate does not cover local direct costs and services cannot be purchased at a lower rate or there is a strong desire to continue clinical relationship • In VA, local direct costs are defined as: variable labor, variable supply and direct fixed costs as determined by Decision Support System (VA’s cost accounting system) • For non-clinical services, conduct local analysis of direct costs

  5. Outpatient RatesCMAC less 10% • Professional fee plus ancillary and pharmacy • If no CMAC available… • CMS rate • Negotiated substitute rate based on incremental cost • Does not apply to reference lab agreements – use incremental cost instead • Should be separated from support/tenant services

  6. Inpatient Methodology • TRICARE rates less 10% x DRG • TRICARE methodology for outliers • Guidance will address professional services, anesthesiology, mental health, durable medical equipment, transfer patients, ambulance service, waivers, etc. • Goal is to have guidance ready for HEC approval in April/May

  7. Open Discussion

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