OFFICE
OF MANAGEMENT AND BUDGET
Cost
of Hospital and Medical Care Treatment Furnished by the United States;
Certain Rates Regarding Recovery From Tortiously Liable Third Persons
By
virtue of the authority vested in the President by Section 2(a)
of P.L. 87-693 (76 Stat. 593; 42 U.S.C.2652), and delegated to
the Director of the Office of Management and Budget by Executive
Order No. 11541 of July 1, 1970 (35 Federal Register 10737), the
two sets of rates outlined below are hereby established. These
rates are for use in connection with the recovery, from tortiously
liable third persons, of the cost of hospital and medical care
and treatment furnished by the United States (Part 43, Chapter
I, Title 28, Code of Federal Regulations) through three separate
Federal agencies. The rates have been established in accordance
with the requirements of OMB Circular A-25, requiring reimbursement
of the full cost of all services provided. The rates are established
as follows:
1.
Department of Defense
The
FY 1999 Department of Defense (DoD) reimbursement rates for inpatient,
outpatient, and other services are provided in accordance with
Section 1095 of title 10, United States Code. Due to size, the
sections containing the Drug Reimbursement Rates (Section III.E)
and the rates for Ancillary Services Requested by Outside Providers
(Section III.F) are not included in this package. The Office of
the Assistant Secretary of Defense (Health Affairs) will provide
these rates upon request. The medical and dental service rates
in this package (including the rates for ancillary services, prescription
drugs or other procedures requested by outside providers) are
effective October 1, 1998.
2.
Health and Human Services
The
sum of obligations for each cost center providing medical service
is broken down into amounts attributable to inpatient care on
the basis of the proportion of staff devoted to each cost center.
Total inpatient costs and outpatient costs thus determined are
divided by the relevant workload statistic (inpatient day, outpatient
visit) to produce the inpatient and outpatient rates. In calculation
of the rates, the Department's unfunded retirement liability cost
and capital and equipment depreciation cost were incorporated
to conform to requirements set forth in OMB Circular A-25. In
addition, each cost center's obligations include obligations from
certain other accounts, such as Medicare and Medicaid collections
and Contract Health funds that were used to support direct program
operations. Certain cost centers that primarily support workload
outside of the directly operated hospitals or clinics (public
health nursing, public health nutrition, health education) were
excluded. These obligations are not a part of the traditional
cost of hospital operations and do not contribute directly to
the inpatient and outpatient visit workload. Overall, these rates
reflect a more accurate indication of the cost of care in HHS
facilities.
In
addition, separate rates per inpatient day and outpatient visit
were computed for Alaska and the rest of the United States. This
gives proper weight to the higher cost of operating medical facilities
in Alaska.
1.
Department of Defense
For
the Department of Defense, effective October 1, 1998 and thereafter:
Inpatient,
Outpatient And Other Rates And Charge.
Inpatient Rates 1 2
|
International
military education per inpatient day |
Interagency&
Other Federal Agency &Training (IMET) |
Other
Sponsored Patients |
| A.
Burn Center |
$2,538.00 |
$4,632.00 |
$4,952.00 |
B.
Surgical Care Services
(Cosmetic Surgery) |
$1,236.00 |
$2,255.00 |
$2,411.00 |
C.All
Other Inpatient Services (Based on Diagnosis Related Groups
(DRG) 3)
1.FY99
Direct Care Inpatient Reimbursement Rates
| Adjusted
standard amount |
IMET |
Interagency |
Other (full/third party) |
|
Large Urban |
$2,429.00 |
$4,552.00 |
$4,825.00 |
|
Other Urban/Rural |
$2,642.00 |
$5,413.00 |
$5,760.00 |
|
Overseas |
$2,989.00 |
$6,823.00 |
$7,234.00 |
2.
Overview
The
FY99 inpatient rates are based on the cost per DRG, which is the
inpatient full reimbursement rate per hospital discharge weighted
to reflect the intensity of the principal diagnosis,
secondary diagnoses, procedures, patient age, etc. involved.
The average cost per Relative Weighted Product (RWP) for large
urban, other urban/rural, and overseas facilities will be published
annually as an inpatient adjusted standardized amount (ASA) (see
paragraph I.C.1. above). The ASA will be applied to the RWP for
each inpatient case, determined from the DRG weights, outlier
thresholds, and payment rules published annually for hospital
reimbursement rates under the Civilian Health and Medical Program
of the Uniformed Services (CHAMPUS) pursuant to 32 CFR 199.14(a)(1),
including adjustments for length of stay (LOS) outliers. The published
ASAs will be adjusted for area wage differences and indirect medical
education (IME) for the discharging hospital. An example of how
to apply DoD costs to a DRG standardized weight to arrive at DoD
costs is contained in paragraph I.C.3., below.
3.
Example of Adjusted Standardized Amounts for Inpatient Stays
Figure
1 shows examples for a nonteaching hospital in a Large Urban
Area.
a.
The cost to be recovered is DoD's cost for medical services provided
in the nonteaching hospital located in a large urban area. Billings
will be at the third party rate.
b.
DRG 020: Nervous System Infection Except Viral Meningitis. The
RWP for an inlier case is the CHAMPUS weight of 2.9769. (DRG statistics
shown are from FY 1997).
c.
The DoD adjusted standardized amount to be charged is $4,825 (i.e.,
the third party rate as shown in the table).
d.
DoD cost to be recovered at a nonteaching hospital with area wage
index of 1.0 is the RWP factor (2.9769 ) in 3.b., above, multiplied
by the amount ($4,825) in 3.c., above.
e.
Cost to be recovered is $14,364.
FIGURE
1. THIRD PARTY BILLING EXAMPLES
| DRG
No. |
DRG
Description |
DRG
Weight |
Arithmetic
Mean LOS |
Geometric
Mean LOS |
Short
Stay Threshold |
Long
Stay Threshold |
020 |
Nervous
System Infection Except Viral Meningitis |
2.9769 |
11.2 |
7.8 |
1 |
30 |
| Hospital |
Location |
Area
Wage Rate Index |
IME
Adjustment |
Group
ASA |
Applied
ASA |
| Nonteaching Hospital |
Large
Urban |
1.0 |
1.0 |
$4,825.00 |
$4,825.00 |
| |
Relative
Weighted Product |
|
| Patient |
Length
of Stay |
Days
Above Threshold |
Inlier* |
Outlier** |
Total |
TPC
amount*** |
| #1 |
7
days |
0 |
2.9769 |
0.0000 |
2.9769 |
$14,364 |
| #2 |
21
days |
0 |
2.9769 |
0.0000 |
2.9769 |
$14,364 |
| #3 |
35
days |
5 |
2.9769 |
0.6297 |
3.6066 |
$17,402 |
*
DRG Weight
**
Outlier calculation = 33 percent of per diem weight × number
of outlier days
=
.33 (DRG Weight/Geometric Mean LOS) × (Patient LOS - Long Stay
Threshold)
=
.33 (2.9769/7.8) × (35-30)
=
.33 (.38165) × 5 (take out to five decimal places)
=
.12594 × 5 (take out to five decimal places)
=
.6297 (take out to four decimal places)
- ***
Applied ASA × Total RWP
e="2" face="Verdana, Arial, Helvetica, sans-serif">II. Outpatient
Rates 1 2 Per Visit
III.
Other Rates And Charges 1 2 Per Visit
MEPRS Code 4 |
Clinical Service |
International Military Education & Training (IMET) |
Interagency
& Other Federal Agency Sponsored Patients |
Other (full/third party) |
| FBI |
A.
Immunization |
$13.00 |
$22.00 |
$24.00 |
| DGC |
B.
Hyperbaric Chamber 5 |
191.00 |
343.00 |
366.00 |
| |
C.
Ambulatory Procedure Visit (APV) 6 |
926.00 |
1,657.00 |
1,765.00 |
| |
D.
Family Member Rate (formerly Military Dependents Rate) |
10.45 |
.......... |
.......... |
E.
Reimbursement Rates For Drugs Requested By Outside Providers
7
- The
FY 1999 drug reimbursement rates for drugs are for prescriptions
requested by outside providers and obtained at a Military Treatment
Facility. The rates are established based on the cost of the particular
drugs provided. Final rule 32 CFR Part 220 eliminates the high
cost ancillary services' dollar threshold and the associated term
"high cost ancillary service." The phrase "high cost ancillary
service" will be replaced with the phrase "ancillary services
requested by an outside provider" on publication of final rule
32 CFR Part 220. The list of drug reimbursement rates is too large
to include here. These rates are available on request from OASD
(Health Affairs).
F.
Reimbursement Rates for Ancillary Services Requested By Outside
Providers 8
- Final
rule 32 CFR Part 220 eliminates the high cost ancillary services'
dollar threshold and the associated term "high cost ancillary
service." The phrase "high cost ancillary service" will be replaced
with the phrase "ancillary services requested by an outside provider"
on publication of final rule 32 CFR Part 220. The list of FY 1999
rates for ancillary services requested by outside providers and
obtained at a Military Treatment Facility is too large to include
here. These rates are available on request from OASD(Health Affairs).
G.
Elective Cosmetic Surgery Procedures and Rates
Cosmetic Surgery Procedure |
International
Classification Diseases (ICD-9) |
Current
Procedural Terminology (CPT) 9 |
FY 1999 Charge 10 |
Amount
of Charge |
| Mammaplasty |
85.50,
85.32, 85.31 |
19325,
19324, 19318 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Mastopexy |
85.60 |
19316 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Facial
Rhytidectomy |
86.82,
86.22 |
15824 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Blepharoplasty |
08.70,
08.44 |
15820,
15821, 15822, 15823 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Mentoplasty
(Augmentation/Reduction) |
76.68,
76.67 |
21208,
21209 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Abdominoplasty |
86.83 |
15831 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Lipectomy
suction per region 11 |
86.83 |
15876,
15877, 15878, 15879 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Rhinoplasty |
21.87,
21.86 |
30400,
30410 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Scar
Revisions beyond CHAMPUS |
86.84 |
15785 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Mandibular
or Maxillary Repositioning |
76.41 |
21194 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Minor
Skin Lesions 12 |
86.30 |
15785 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Dermabrasion |
86.25 |
15780 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Hair
Restoration |
86.64 |
15775 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Removing
Tattoos |
86.25 |
15780 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Chemical
Peel |
86.24 |
15790 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Arm/Thigh
Dermolipectomy |
86.83 |
15839 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
| Brow
Lift |
86.3 |
15839 |
Inpatient
Surgical Care Per Diem
Or
APV or applicable Outpatient Clinic Rate |
(a
b c) |
H.
Dental Rate 13 Per Procedure
MEPRS Code 4 |
Clinical Service |
International Military Education & Training (IMET) |
Interagency
& Other Federal Agency Sponsored Patients |
Other (full/third party) |
| |
Dental Services, ADA code and DoD established weight |
$56.00 |
$101.00 |
$108.00 |
I.
Ambulance Rate 14 Per Visit
| MEPRS
Code 4 |
Clinical Service |
International Military Education & Training (IMET) |
Interagency
& Other Federal Agency Sponsored Patients |
Other
(full/third party) |
| FEA |
Ambulance |
$56.00 |
$101.00 |
$107.00 |
J.
Ancillary Services Requested by an Outside Provider 8
Per Procedure
MEPRS Code 4 |
Clinical Service |
International Military Education & Training (IMET) |
Interagency
& Other Federal Agency Sponsored Patients |
Other (full/third party) |
| |
Laboratory
procedures requested by an outside provider CPT '98 Weight
Multiplier |
$10.00 |
$17.00 |
$18.00 |
| |
Radiology
procedures requested by an outside provider CP '98 Weight
Multiplier |
25.00 |
45.00 |
48.00 |
| |
Cardiology procedures requested by an outside provider CPT
'98 Weight Multiplier |
17.00 |
31.00 |
33.00 |
K.
AirEvac Rate 15 Per Visit
MEPRS Code 4 |
Clinical Service |
International Military Education & Training (IMET) |
Interagency
& Other Federal Agency Sponsored Patients |
Other (full/third party) |
| |
AirEvac
Services - Ambulatory |
$90.00 |
$161.00 |
$172.00 |
| |
AirEvac
Services - Litter |
256.00 |
459.00 |
489.00 |
Observation
Rate 16 Per hour
MEPRS Code 4 |
Clinical Service |
International Military Education & Training (IMET) |
Interagency
& Other Federal Agency Sponsored Patients |
Other (full/third party) |
| |
Observation
Services Hour |
$14.50 |
$25.83 |
$27.50 |
Notes
on Cosmetic Surgery Charges
a
Per diem charges for inpatient surgical care services are listed
in Section I.B. (See notes 9 through 11, below, for further
details on reimbursable rates.)
|
