[Federal Register Volume 60, Number 229 (Wednesday, November 29, 1995)]
[Notices]
[Pages 61450-61452]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-29043]



      

[[Page 61449]]

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Part VII





Office of Management and Budget





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Cost of Hospital and Medical Care and Treatment Furnished by the United 
States; Certain Rates Regarding Recovery From Tortiously Liable Third 
Persons; Notice

  Federal Register / Vol. 60, No. 229 / Wednesday, November 29, 1995 / 
Notices   

[[Page 61450]]


OFFICE OF MANAGEMENT AND BUDGET


Cost of Hospital and Medical Care and 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 FR 10737), the three 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 1996 inpatient rates are based on 
the cost per Diagnostic Related Group (DRG), which is the inpatient 
full reimbursement rate per hospital discharge, weighted to reflect the 
intensity of the principal diagnosis 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 
standardized amount.
    The adjusted standardized amounts (ASA) per Relative Weighted 
Product (RWP) for use in the Direct Care System will be comparable to 
procedures utilized by Health Care Financing Administration (HCFA) and 
the Civilian Health and Medical Program for the Uniformed Services 
(CHAMPUS). These expenses will include all direct care expenses. The 
average cost per relative weighted product for large urban, other 
urban/rural and overseas facilities will be published annually as an 
inpatient standardized amount and will include the cost of inpatient 
professional services. The DRG rates will apply to reimbursement from 
all sources. A relative weight for each DRG using the standardized 
amount will be the same as the DRG weights 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) which includes adjustments for outliers, area wages, and 
indirect medical education.
    (2) Department of 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 all costs for accounts, such as Medicare and Medicaid 
collections and Contract Health funds used to support direct program 
operation. Inclusion of these funds yields a more accurate indication 
of the cost of care in HHS facilities.
    (3) Department of Veterans Affairs. The actual costs and per diem 
rates by type of care the previous year are added to the facility 
overhead costs and then adjusted by the budgeted percentage change for 
the current year and the budget year to compute the base rate for the 
budget year. The base rate is then adjusted by the estimated cost for 
depreciation of buildings and equipment, central office overhead, 
Government employee retirement and disability charges, and return on 
fixed assets (interest on capital for land, buildings and equipment 
(net book value)), to compute the budget year tortiously liable 
reimbursement rates. Also shown for inpatient per diem rates are 
breakdowns into three cost components: Physician; Ancillary; and 
Nursing, Room and Board. As with the total per diem rates, these 
breakdowns are calculated from actual data by type of care for the 
previous year.
    These rates represent the reasonable cost of hospital, nursing 
home, medical, surgical, or dental care and treatment (including 
prostheses and medical appliances) furnished or to be furnished by the 
United States in Federal hospitals, nursing homes, and outpatient 
clinics administered by the Department of Defense, the Department of 
Veterans Affairs and the Department of Health and Human Services.
    For such care and treatment furnished at the expense of the United 
States in a facility not operated by the United States, the rates shall 
be the amounts expended for such care and treatment.
    For the Department of Defense, effective October 1, 1995 and 
thereafter:

I. Inpatient Rates (Per Inpatient Day)\1\

                                                                        
                                                               Full     
                                                           reimbursement
                                                               rate     
                                                                        
A. Burn Center..........................................          $3,794
B. Surgical Care Services (Cosmetic Surgery)............          1,567 
C. All Other Inpatient Services (Based on Diagnosis Related Groups (DRG)
 Charges)                                                               
                                                                        

1. FY 1996 Direct Care Inpatient Reimbursement Rates (Adjusted 
Standard)

                                                                        
                                                             Full cost  
                                                                        
Large Urban.............................................          $4,713
Other Urban/Rural.......................................           4,745
Overseas................................................           6,038
                                                                        

2. Overview

    The FY 1996 inpatient rates are based on the cost per DRG which 
is the inpatient full reimbursement rate per hospital discharge, 
weighed to reflect the intensity of the principal diagnosis 
involved. The average costs per Relative Weighted Product (RWP) for 
large urban, other urban/rural and overseas facilities will be 
published annually as an inpatient standardized amount. (See item 1 
above). A ``relative weighted product'' for each DRG case to apply 
to the standardized amount will be determined from DRG weights 
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) with adjustments for 
outliers. Standardized amounts will be adjusted for area wage 
differences and indirect medical education. An example of how to 
apply DoD costs to a DRG standardized weight to arrive at DoD costs 
is contained in part 3 of Section I.C., below.

3. Example of Adjusted Standardized Amounts for Procedures 
Performed

Large Urban Area--Example

    a. The cost to be recovered is DoD's cost for medical services 
provided in a large urban area. Billings will be at the third party 
rate.
    b. DRG 020: Nervous System infection except viral meningitis. 
Relative Weighed Product for an inlier case is the CHAMPUS weight of 
2,0327.
    c. The DoD adjusted standardized amount to be recovered is 
$4,713 (i.e., the third party rate as shown in the table).
    d. DoD cost to be recovered at a non-teaching hospital with area 
wage index of 1.0 is the RWP factor (2,0327) in item 3.b., above, 
times the amount ($4,713) in 3.c., above.
    Cost to be recovered is $9,580.

II. Outpatient Rates\1\

                                                                        
                                                               Full     
           Code                   Clinical services        reimbursement
                                                               rate     
                                                                        
                             A. Medical Care                            
                                                                        
BAA                         Internal Medicine...........            $163
BAB                         Allergy.....................              56
BAC                         Cardiology..................             116
BAE                         Diabetes....................              70
BAF                         Endocrinology...............            152 

[[Page 61451]]
                                                                        
BAG                         Gastroenterology............             190
BAH                         Hematology..................             269
BAI                         Hypertension................              60
BAJ                         Nephrology..................             230
BAK                         Neurology...................             177
BAL                         Nutrition...................              51
BAM                         Oncology....................             157
BAN                         Pulmonary Disease...........             205
BAO                         Rheumatology................             147
BAP                         Dermatology.................             100
BAQ                         Infectious Disease..........             139
BAR                         Physical Medicine...........             132
                                                                        
                             B. Surgical Care                           
                                                                        
BBA                         General Surgery.............             193
BBB                         Cardiovascular/Thoracic                  183
                             Surgery.                                   
BBC                         Neurosurgery................             228
BBD                         Ophthalmology...............             131
BBE                         Organ Transplant............             262
BBF                         Otolaryngology..............             150
BBG                         Plastic Surgery.............             170
BBH                         Proctology..................             159
BBI                         Urology.....................             174
BBJ                         Pediatric Surgery...........             125
                                                                        
                C. Obstetrical and Gynecological (OB-GYN)               
                                                                        
BCA                         Family Planning.............              87
BCB                         Gynecology..................             118
BCC                         Obstetrics..................             113
                                                                        
                            D. Pediatric Care                           
                                                                        
BDA                         Pediatric...................              88
BDB                         Adolescent..................              86
BDC                         Well Baby...................              64
                                                                        
                           E. Orthopaedic Care                          
                                                                        
BEA                         Orthopaedic.................             163
BEB                         Cast Clinic.................              69
BEC                         Hand Surgery................              69
BEE                         Orthopaedic Appliance.......             112
BEF                         Podiatry....................              79
BEZ                         Chiropractic Clinic.........              49
                                                                        
                 F. Psychiatric and/or Mental Health Care               
                                                                        
BFA                         Psychiatry..................             165
BFB                         Psychology..................             135
BFC                         Child Guidance..............              56
BFD                         Mental Health...............             119
BFE                         Social Work.................             129
BFF                         Substance Abuse                           98
                             Rehabilitation.                            
                                                                        
                         G. Primary Medical Care                        
                                                                        
BGA                         Family Practice.............             105
BHA                         Primary Care................             102
BHB                         Medical Examination.........              93
BHC                         Optometry...................              71
BHD                         Audiology Clinic............              57
BHE                         Speech Pathology............              88
BHF                         Community Health............              80
BHG                         Occupational Health.........              84
BHI                         Immediate Care Clinic.......            139 
                        H. Emergency Medical Care                       
                                                                        
BIA                         Emergency Care Clinic 163...                
                                                                        
                        I. Flight Medicine Clinic                       
                                                                        
BJA                         Flight Medicine.............             151
                                                                        
                        J. Underseas Medicine Care                      
                                                                        
BKA                         Underseas Medicine Clinic 65                
                                                                        
                        K. Rehabilitative Services                      
                                                                        
BLA                         Physical Therapy............              49
                                                                        
BLB                         Occupational Therapy........              96
BLC                         Neuromuscular Skeletal                    37
                             Screening.                                 
                                                                        
                                 L. Same Day Surgery                 767
                                                                        



III. Other Rates and Charges

                                                                        
                                                               Full     
                                                           reimbursement
                                                               rate     
                                                                        
A. Immunizations........................................             $18
B. Hyperbaric Services:                                                 
  1-60 minutes..........................................             233
  61-120 minutes........................................             452
  121-180 minutes.......................................             671
  181-240 minutes.......................................             889
  Each Additional Hour (Note: Charges may be prorated                   
   based on usage)......................................             233
C. Family Member Rate (Formerly Military Dependents                     
 Rate)..................................................            9.70
                                                                        

    For the Department of Health and Human Services, Indian Health 
Service, effective October 1, 1995 and thereafter:

                                                                        
                                                                   HHS  
                                                                        
Hospital Care Inpatient Day:                                            
  General Medical Care.........................................   $2,018
Outpatient Medical Treatment:                                           
  Outpatient Visit.............................................      195
                                                                        

    For the Department of Veterans' Affairs effective October 1, 
1995 and thereafter:

                 Hospital Care, rates per inpatient day                 
                                                                        
General Medicine...............................................     $966
  Physician....................................................      116
  Ancillary....................................................      252
  Nursing, Room and Board......................................      598
Surgery........................................................    1,576
  Physician....................................................      174
  Ancillary....................................................      478
  Nursing, Room and Board......................................      924
General Psychiatry.............................................      458
  Physician....................................................       43
  Ancillary....................................................       72
  Nursing, Room and Board......................................      343
Intermediate Medicine..........................................      337
  Physician....................................................       17
  Ancillary....................................................       49
  Nursing, Room and Board......................................      271
Neurology......................................................      847
  Physician....................................................      124
  Ancillary....................................................      224
  Nursing, Room and Board......................................      499
Rehabilitation Medicine........................................      712
  Physician....................................................       81
  Ancillary....................................................      218
  Nursing, Room and Board......................................      413
Blind Rehabilitation...........................................      859
  Physician....................................................       69
  Ancillary....................................................      427
  Nursing, Room and Board......................................      363
Spinal Cord Injury.............................................      855
  Physician....................................................      106
  Ancillary....................................................      215
  Nursing, Room and Board......................................      534
  Substance Abuse (Alcohol and Drug Treatment).................      295
  Physician....................................................       28
  Ancillary....................................................       68
  Nursing, Room and Board......................................      199
                                                                        
                     Nursing Home Care, rates per day                   
                                                                        
  Nursing Home Care............................................      266
  Physician....................................................        8
  Ancillary....................................................       36
  Nursing, Room and Board......................................      222
                                                                        
                 Outpatient Medical and Dental Treatment                
                                                                        
Outpatient Visit...............................................      205
  Emergency Dental Outpatient Visit............................      104
  Prescription Filled..........................................       20
                                                                        

Notes

    1. Pursuant to the provisions of 10 U.S.C. 109, the inpatient 
Diagnosis Related Groups are 96 percent hospital and 4 percent 
professional fee. The outpatient per visit percentages are 58 
percent hospital, 29 percent ancillary and 13 percent professional.
    2. The Medical Expense and Performance Reporting System (MEPRS) 
code is a three digit code which defines the summary account and the 
subaccount within a functional category in the DoD medical system. 
An example of this hierarchical arrangement is as follows:

                                                                        
    Outpatient Care (Functional Category)             MEPRS Code        
                                                                        
Medical Care (Summary Account)..............  BA                        
Internal Medicine (Subaccount)..............  BAA                       
                                                                        

    MEPRS codes are used to ensure that consistent expense and 
operating performance data is reported in the DoD military medical 
system.
    For the period beginning October 1, 1995, the rates prescribed 
herein superseded those established by the Director of the Office of 


[[Page 61452]]
Management and Budget October 24, 1994 (59 FR 53492).
Alice M. Rivlin,
Director, Office of Management and Budget.
[FR Doc. 95-29043 Filed 11-28-95; 8:45 am]
BILLING CODE 3110-01-P