Following several years of advocacy by the business community about medical costs in the workers' compensation system, the Workers' Compensation Board last year issued a RFP for consulting assistance to develop a fee schedule for health care facilities such as hospitals and ambulatory surgical facilities. Professional services have been governed by WCB Rule Chapter 5 for many years. The Board worked with Eric Anderson with Ingenix to develop the background for a facility fee schedule and then convened a so-called "consensus-based" rulemaking group to determine if consensus can be achieved on the methodology for a fee schedule. The MMA and the ambulatory surgical facilities are participating in the group. At the first meeting on April 22, 2008, the WCB staff provided copies of the following draft amendment to Rule Chapter 5.
Section 1. Definitions.
(a) Acute care hospital
(b) Ambulatory Payment Classification System
(c) Ambulatory Surgical Center (ASC)
(d) Critical Access Hospital
(e) Durable Medical Equipment
(f) Implantable
(g) Inpatient services
(h) MS-DRG
(i) Outpatient services
Section 2. Inpatient
(a) Billing for inpatient services must be submitted on a CMS Uniform Billing (UB-04) form.
(b) A critical access hospital shall be reimbursed at 95% of its usual and customary charge.
(c) Payments for inpatient services in an acute care hospital are based on the MS-DRG system. The payment must be calculated by multiplying the base rate times the current MS-DRG weight. The base rate for inpatient services at acute care hospitals is $8923.00.
(d) Except as provided in subsections (e) and (f), acute care hospitals shall be paid the maximum allowable payment established in Appendix IV or its usual and customary charge, whichever is less, for inpatient services.
(e) The threshold for outlier payments is $50,000.00 plus the maximum allowable charge established in Appendix IV If the outlier threshold is met, the outlier payment must be the maximum allowable charge plus the charges above the sum of the threshold and the maximum allowable charge multiplied by 75%. The total payment for the services is the outlier payment plus the maximum allowable charge.
(f) Where an implantable exceeds $10,000 in cost, acute care hospitals may seek additional reimbursement beyond the maximum allowable charge. For invoiced items, reimbursement is set at the actual amount paid plus 20%. If an item is not invoiced, the payment must be 75% of charges. When a hospital seeks additional reimbursement pursuant to this rule, the implantable charge is excluded from any calculation for an outlier payment. Handling and freight charges must be included in the facility's invoiced cost and are not to be reimbursed separately.
(g) All services provided during an uninterrupted patient encounter leading to an inpatient admittance must be included in the inpatient stay.
(h) The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two acute care hospitals:
(1) A hospital transferring a patient is paid as follows: The MS-DRG reimbursement amount is divided by the number of days duration listed for the DRG; the resultant per diem amount is then multiplied by two for the first day of stay at the transferring hospital; the per diem amount is multiplied by one for each subsequent day of stay at the transferring hospital; and the amounts for each day of stay at the transferring hospital are totaled. If the result is greater than the MS-DRG reimbursement amount, the transferring hospital is paid the MS-DRG reimbursement amount. Associated outliers and add-ons are then added to the payment.
(2) A hospital discharging a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons.
(3) Facility transfers do not include costs related to transportation of a patient to obtain medical care.
(h) Services provided by an acute care hospital that do not have a maximum charge in Appendix IV shall be paid at 75% of the acute care hospital’s usual and customary charge.
(i) Services provided by an inpatient rehabilitation facility shall be paid at 75% of the inpatient rehabilitation facility’s usual and customary charge.
(j) Individual medical providers who furnish professional services in a hospital, ASC, or other facility setting must bill insurers directly and must be reimbursed using the maximum fees set forth in Appendix III. The individual medical provider’s charges are excluded from any calculation of outlier payments.
Section 3. Outpatient and ambulatory surgical care centers
(a) Billing for outpatient services must be submitted on a CMS Uniform Billing (UB-04) form.
(b) The base rate for outpatient services at acute care hospitals is $108.42.
(c) The base rate for inpatient services at ambulatory surgical care centers is $81.32.
(d) Outpatient services include observation in an outpatient status.
(e) Except as provided in subsections (g) and (h), acute care hospitals and ambulatory surgical care centers shall be paid the maximum allowable payment established in Appendix V or its usual and customary charge, whichever is less, for outpatient services.
(f) Payments for outpatient services in an acute care hospital or an ambulatory surgical care centers are based on the APC system. The payment must be calculated by multiplying the base rate times the APC weight.
(1) If the APC weight is not listed or if the APC weight is listed as null for items with status codes A, B, C, D, E, F, K, L, M, Q, S, T, V, X, Y then reimbursement must be paid at 75 percent of usual and customary charges. For items with status code of N or items with no CPT/HCPCS code, there is no separate payment.
(2) When two or more T status code items are on the same claim, the highest weighted code is paid at 100 percent of the APC payment and subsequent T status code items are paid at 50 percent of the APC payment.
(3) “Q” status indicator codes will not be discounted.
(g) The threshold for outlier payments is $2,500 per CPT code plus the maximum allowable charge as defined in paragraph (e). If the outlier threshold is met, the outlier payment must be the maximum allowable charge as defined in paragraph (e), plus the charges above the threshold multiplied by 75 percent.
(h) Where an implantable exceeds $5,000.00 in cost, hospitals or ambulatory surgical care centers may seek additional reimbursement. For invoiced items, reimbursement is set at the actual amount paid plus 20 percent. If an item is not invoiced, the payment must be 75 percent of charges. When an ambulatory surgical care center or hospital seeks additional reimbursement pursuant to this rule, the implantable charge is excluded from any calculation for an outlier payment. Handling and freight charges must be included in the facility's invoiced cost and are not to be reimbursed separately.
(i) The following applies to patient transfers from an acute care hospital or ambulatory surgical care center to an acute care hospital:
(1) An acute care hospital or ambulatory surgical care center transferring a patient is paid the maximum allowable charge established in this section.
(2) The acute care hospital to which the patient is transferred is paid the maximum allowable charge established in section 2.
(3) Facility transfers do not include costs related to transportation of a patient to obtain medical care.
(j) Individual medical providers who furnish professional services in a hospital, ASC, or other facility setting must bill insurers directly and must be reimbursed using the maximum fees set forth in Appendix III. The individual medical provider’s charges are excluded from any calculation of outlier payments.
A second and final meeting of the "consensus-based" rulemaking group has been scheduled for Tuesday, May 13, 2008 and the WCB staff is likely to provide a new version of the proposed rule based upon comments made at the last meeting. Then, the rule will enter the formal Administrative Procedures Act rulemaking process.
If you have comments about this proposal, please contact Andrew MacLean, Deputy EVP at amaclean@mainemed.com or by phone at 622-3374, ext. 214 before the 13th.
