[Federal Register Volume 76, Number 154 (Wednesday, August 10, 2011)]
[Notices]
[Pages 49458-49459]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-20235]


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DEPARTMENT OF DEFENSE

Office of the Secretary


TRICARE; Hospital Outpatient Radiology Discretionary Appeal 
Adjustments

AGENCY: Office of the Secretary, Department of Defense (DoD).

ACTION: Notice.

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SUMMARY: This notice is to advise hospitals of an opportunity for net 
adjusted payments for radiology services for which TRICARE payments 
were not comparable to the pre-Outpatient Prospective Payment System 
(OPPS) Medicare fair rates for the period

[[Page 49459]]

August 1, 2003, to May 1, 2009 (or other appropriate end date for OPPS-
exempt hospitals.)

DATES: The agency must receive a hospital's request on or before June 
23, 2011, or October 11, 2011 for hospitals that did not receive 
notification by letter.

ADDRESSES: TRICARE Management Activity (TMA), Medical Benefits and 
Reimbursement Branch, 16401 East Centretech Parkway, Aurora, CO 80011-
9066.

FOR FURTHER INFORMATION CONTACT: Martha M. Maxey, Medical Benefits and 
Reimbursement Branch, TMA, telephone (303) 676-3627.

SUPPLEMENTARY INFORMATION: In reviewing payments for hospital 
outpatient services, DoD has determined that, for radiology services 
specified in the regulation as being reimbursed under the allowable 
charge methodology, the technical component of the allowable charge did 
not approximate the Medicare fair payment for such hospital services as 
well as it could have. That is, in looking at the Medicare 
reimbursement methodologies in existence prior to adoption of 
Medicare's OPPS in 2000, (methodologies resulting in fair payment for 
Federal health care, which TRICARE allowable charges for hospitals 
outpatient services were intended to emulate), some radiology services 
were underpaid in comparison.
    The National Defense Authorization Act for Fiscal Year 2002 
required that TRICARE use Medicare reimbursement rates for hospitals to 
the extent practicable. While payments were made in accordance with 32 
Code of Federal Regulation, 199.14, there is a basis for TRICARE to 
make discretionary net adjusted payments for radiology services for 
which TRICARE payments were not comparable to the pre-OPPS Medicare 
fair rates for the period in question.
    On April 25, 2011, TMA mailed letters to thousands of hospitals 
notifying them of this opportunity. The hospitals (or their recovery 
agents) have until June 23, 2011, 60 days from the date of 
notification, to file an appeal for pay adjustments that will be 
adjudicated by TMA. Hospitals that did not receive notification by mail 
have 60 days from August 10, 2011.
    Critical Access Hospitals (CAHs) which are not subject to TRICARE's 
OPPS shall submit a request for the period August 1, 2003, to November 
30, 2009. As of December 1, 2010, the payments to CAHs are based on 
reasonable cost and thus potential adjustments would not apply. Other 
hospitals not subject to OPPS (such as Cancer and Children's hospitals) 
shall submit a request for the period August 1, 2003, to December 31, 
2010.
    The payment adjustment process along with the notification letter 
to hospitals can be viewed at TMA's Web site at: http://www.tricare.mil/RadiologyDiscretionaryAppealAdjustments.

    Dated: July 8, 2011.
Patricia Toppings,
OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2011-20235 Filed 8-9-11; 8:45 am]
BILLING CODE 5001-06-P