Payment for non-VA physician services associated with either outpatient or inpatient care provided at non-VA facilities--VA. Proposed rule

This document proposes to amend Department of Veterans Affairs (VA) medical regulations concerning payment for non-VA physician services that are associated with either outpatient or inpatient care provided to eligible VA beneficiaries at non-VA facilities. We propose that when a service specific reimbursement amount has been calculated under Medicare's Participating Physician Fee Schedule, VA would pay the lesser of the actual billed charge or the calculated amount. We also propose that when an amount has not been calculated, VA would pay the amount calculated under a 75th percentile formula or, in certain limited circumstances, VA would pay the usual and customary rate. In our view, adoption of this proposal would establish reimbursement consistency among federal health benefits programs, would ensure that amounts paid to physicians better represent the relative resource inputs used to furnish a service, and, would, as reflected by a recent VA Office of Inspector General (OIG) audit of the VA fee-basis program, achieve program cost reductions. Further, consistent with statutory requirements, the regulations would continue to specify that VA payment constitutes payment in full.     

Payment or reimbursement for emergency services for nonservice-connected conditions in non-VA facilities. Final rule

This document amends the Department of Veterans Affairs (VA) ``Payment or Reimbursement for Emergency Services for Nonservice-Connected Conditions in Non-VA Facilities' regulations to conform with a statutory change that expanded veterans' eligibility for reimbursement. Some of the revisions in this final rule are purely technical, matching the language of our regulations to the language of the revised statute, while others set out VA's policies regarding the implementation of statutory requirements. This final rule expands the qualifications for payment or reimbursement to veterans who receive emergency services in non-VA facilities, and establishes accompanying standards for the method and amount of payment or reimbursement.     

VA payment for non-VA public or private hospital care and non-VA physician services that are associated with either outpatient or inpatient care. Department of Veterans Affairs. Final rule

This document amends our medical regulations concerning VA payment for non-VA public or private hospital care provided to eligible VA beneficiaries. This document also amends our medical regulations concerning VA payment for non-VA physician services that are associated with either outpatient or inpatient care provided to eligible VA beneficiaries at non-VA facilities. With certain exceptions, these payments have been based on Medicare methodology. Sometimes VA can negotiate contracts with hospitals or physicians or with their agents to reduce the payment amounts. This document amends these regulations to allow VA to make lower payments based on such negotiations.     

Payment of reimbursement for emergency treatment furnished by non-VA providers in non-VA facilities to certain veterans with service-connected or nonservice-connected disabilities. Final rule

This document amends the Department of Veterans Affairs (VA) medical regulations concerning emergency hospital care and medical services provided to eligible veterans at non-VA facilities. The amendments are required by section 402 of the Veterans' Mental Health and Other Care Improvements Act of 2008. Among other things, the amendments authorize VA to pay for emergency treatment provided to a veteran at a non-VA facility up to the time the veteran can be safely transferred to a VA or other Federal facility and such facility is capable of accepting the transfer, or until such transfer was actually accepted, so long as the non-VA facility made and documented reasonable attempts to transfer the veteran to a VA or other Federal facility.     

Payment for inpatient and outpatient health care professional services at non-departmental facilities and other medical charges associated with non-VA outpatient care. Final rule

This document affirms as final, with changes, a proposed rule that updates the Department of Veterans Affairs (VA) medical regulations concerning the payment methodology used to calculate VA payments for inpatient and outpatient health care professional services and other medical services associated with non-VA outpatient care. The rule has been designed to ensure that it will not have adverse effects on access to care.     

Hospital care and medical services in non-VA facilities--VA. Final rule and regulation

Department of Veterans Affairs (VA) is amending regulations which pertain to the authorization for contract non-VA hospital care and medical services for veterans. The Veterans Health Care Act of 1992 provides that veterans with a total disability permanent in nature from a service-connected disability may be authorized contract non-VA hospital care and medical services. Contract care may be authorized only if the VA facility is not capable of furnishing the care required, or is not capable of furnishing economical care or services because of geographical inaccessibility. This amendment will make the regulations consistent with the law.     

Reasonable charges for medical care or services. Department of Veterans Affairs. Interim final rule

This document amends the Department of Veterans Affairs (VA) medical regulations concerning "reasonable charges" for medical care or services provided or furnished by VA to a veteran: (1) For a nonservice-connected disability for which the veteran is entitled to care (or the payment of expenses of care) under a health plan contract; (2) For a nonservice-connected disability incurred incident to the veteran's employment and covered under a worker's compensation law or plan that provides reimbursement or indemnification for such care and services; or (3) For a nonservice-connected disability incurred as a result of a motor vehicle accident in a State that requires automobile accident reparations insurance. This document amends the regulations to update databases and other provisions for the purpose of providing more precise charges.     

Medical care collection or recovery--VA. Notice

In a companion document published in the "Proposed Rules" section of this issue of the Federal Register, we proposed to amend VA's medical regulations concerning collection or recovery by VA for medical care or services provided or furnished to a veteran: (i) For a non-service connected disability for which the veteran is entitled to care (or the payment of expenses of care) under a health-plan contract; (ii) For a non-service connected disability incurred incident to the veteran's employment and covered under a worker's compensation law or plan that provides reimbursement or indemnification for such care and services; or (iii) For a non-service connected disability incurred as a result of a motor vehicle accident in a State that requires automobile accident reparations insurance. The proposed rule includes methodology for establishing charges for VA medical care or services. Using this methodology, information for calculating proposed charge amounts at individual VA facilities for inpatient facility charges, skilled nursing facility/sub-acute inpatient facility charges, outpatient facility charges, and physician charges is set forth below. If this methodology were adopted subsequently as a final rule, the applicable data in this document, designed for the period August 1998 through September 1999, would be used for the period from the effective date of the final rule through September 1999. Accordingly, interested parties may wish to retain this document for future reference.     

Reimbursement offsets for medical care or services. Final rule

This document amends the regulations of the Department of Veterans Affairs (VA) concerning the reimbursement of medical care and services delivered to veterans for nonservice-connected conditions. This rule applies in situations where third-party payers are required to reimburse VA for costs related to care provided by VA to a veteran covered under the third-party payer's plan. This final rule adds a new section barring offsets by third-party payers and requires that third-party payers submit a request for a refund for claims when there is an alleged overpayment.     

Medicare program; provider reimbursement determinations and appeals. Final rule

Subpart R of 42 CFR part 405 consists of regulations governing Medicare reimbursement determinations, and appeals of those determinations, by health care providers. (For the sake of simplicity, throughout this final rule, we use "reimbursement" to refer to Medicare payment under both the reasonable cost and prospective payment systems.) Under section 1878 of the Social Security Act (the Act) and the subpart R regulations, the Provider Reimbursement Review Board (the Board) has the authority to adjudicate certain substantial reimbursement disputes between providers and fiscal intermediaries (intermediaries). Board decisions are subject to review by the CMS Administrator, and the final agency decision of the Board or the Administrator, as applicable, is reviewable in Federal district court. In addition, under the subpart R regulations, intermediaries have the authority to hold hearings and adjudicate certain other payment and reimbursement disputes with providers. This final rule updates, clarifies, and revises various provisions of the regulations governing provider reimbursement determinations, appeals before the Board, appeals before the intermediaries (for lesser disputes), and Administrator review of decisions made by the Board.     

Beneficiary travel under 38 U.S.C. 111 within the Unites. Final rule

This document amends the beneficiary travel regulations of the Department of Veterans Affairs (VA) that provide a mechanism for payment of travel expenses within the United States under 38 U.S.C. 111 to help veterans and other persons obtain care and services from VA's Veterans Health Administration (VHA). The amended regulations more fully implement the statutory provisions governing such payments.     

Reasonable charges for medical care or services. Final rule

This final rule amends the Department of Veterans Affairs (VA) medical regulations concerning "reasonable charges" for medical care or services provided or furnished by VA to certain veterans for nonservice-connected disabilities. It changes the process for determining interim billing charges when a new Diagnosis Related Group (DRG) code or Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCS) code identifier is assigned to a particular type or item of medical care or service and VA has not yet established a charge for the new identifier. This process is designed to provide interim billing charges that are very close to what the new billing charges would be when the charges for the new identifiers are established in accordance with the regulations. This final rule also changes the regulations by removing all of the provisions for discounts of billed charges. This will eliminate or reduce duplicate discounting and thereby prevent unintended underpayments to the government.     

Medicare program; physician liability on non-assigned claims--HCFA. Final rule

This rule establishes in regulations the circumstances in which a nonparticipating physician who does not accept Medicare assignment of a claim is required to refund to the beneficiary any amounts collected for physician services determined to be not reasonable and necessary. Its purpose is to extend limitation of liability protection to beneficiaries with non-assigned claims when the physician knew or could reasonably have been expected to know that Medicare would deny payment for the services. Physician appeal rights are also specified. This rule conforms our regulations to section 9332(c) of the Omnibus Budget Reconciliation Act of 1986.     

Medicare program: special payment limits for home oxygen--HCFA. Proposed notice

This notice would establish special payment limits for home oxygen. Currently, payment under the Medicare program for home oxygen and other items of durable medical equipment is equal to 80 percent of the lesser of the actual charge for the item or the fee schedule amount for the item. Based on our experience and after consulting with representative of home oxygen suppliers, we have determined that the Medicare fee schedule amounts for home oxygen are grossly excessive and are not inherently reasonable because they are excessively high relative to the payment and amount for similar services by the Department of Veterans Affairs which uses a true competitive payment methodology. This notice would replace the use of fee schedule amount and proposes that payment for home oxygen be equal to 80 percent of the lesser of the actual charge or a special payment limit set by HCFA, which would vary by locality. It is intended to prevent continuation of excessive payment. The special limit would be based on the average payment amount for home oxygen services by the Department of Veterans Affairs.     

Medicare program; clarification of Medicare's accrual basis of accounting policy--HCFA. Final rule

This final rule revises the Medicare regulations to clarify the concept of "accrual basis of accounting" to indicate that expenses must be incurred by a provider of health care services before Medicare will pay its share of those expenses. This rule does not signify a change in policy but, rather, incorporates into the regulations Medicare's longstanding policy regarding the circumstances under which we recognize, for the purposes of program payment, a provider's claim for costs for which it has not actually expended funds during the current cost reporting period.     

Medicare program: access to books, documents, and records of subcontractors--Health Care Financing Administration

These regulations implement section 952 of the Omnibus Reconciliation Act of 1980 (Pub. L. 96-499), which conditions Medicare reimbursement for the cost of services performed under certain contracts upon compliance with prescribed criteria. If a contract between a provider and a subcontractor covers services valued at or costing $10,000 or more over a 12-month period, Medicare reimbursement cannot be made for the services unless the contract includes a clause allowing the Secretary of Health and Human Services and the Comptroller General access to the contract and to the subcontractor's books, documents, and records necessary to verify the costs of the contract. The clause in the contract must also permit similar access top any subcontract between the subcontractor and a related organization of the subcontractor when the subcontract is worth or costs $10,000 or more over a 12-month period. These regulations specify the criteria and procedures that the Department will use to obtain access to affected books, documents, and records. The purpose of the legislation and these proposed regulations is to permit the Secretary and Comptroller General to make an accurate determination of the reasonable costs under these contracts.