Current through Register Vol. 18, September 20, 2024
(1) The department
adopts the fee schedules provided by this rule to determine the reimbursement
for medical services provided by a facility when a person is discharged on or
after July 1, 2013. An insurer is obligated to pay the fee provided by the fee
schedules for a service, even if the billed charge is less, unless the facility
and insurer have a managed care organization (MCO) or preferred provider
organization (PPO) arrangement that provides for a different payment amount.
The fee schedules are available online at the department's web site and are
updated as soon as is reasonably feasible relative to the effective dates of
the medical codes as described below. The fee schedules are comprised of the
elements listed in
39-71-704, MCA, and the following:
(a) The Montana Status Indicator (SI) Codes;
(b) The Montana unique code,
MT003, described in (11)(e) and (12)(f); and
(c) The base rates and conversion formulas
are established by the department..
(d) All current and prior instruction sets
for services provided starting July 1, 2013, are available on the department's
website.
(2) The
application of the base rate depends on the date the medical services are
provided.
(3) Critical access
hospitals (CAH) are reimbursed at 100 percent of that facility's usual and
customary charges. CAH is a designation for a facility only. The reimbursement
rate for CAH set by this rule applies to facility charges.
(a) Regarding professional services provided
at a physical therapy (PT), occupational therapy (OT), and speech therapy (ST)
services provided on an outpatient basis must be billed on a UB04 and
reimbursed 100 percent of usual and customary. PT, OT, and ST outpatient
services may not be billed on the CMS 1500.
(b) All other professional services provided
at a CAH must be billed on a CMS 1500 and reimbursed according to the
professional fee schedule pursuant to ARM
24.29.1534.
(4) Any services provided by a type of
facility not explicitly addressed by this rule or any services using new codes
not yet adopted by this rule must be paid at 75 percent of the facility's usual
and customary charges.
(5) Any
inpatient rehabilitation services, including services provided at a long- term
inpatient rehabilitation facility must be paid at 75 percent of that facility's
usual and customary charges. All CMS rehabilitation MS-DRGs are excluded from
the Montana MS-DRG payment system and instead are paid at 75 percent of the
facility's usual and customary charges regardless of the place of
service.
(6) DME, prosthetics, and
orthotics, excluding implantables, will be paid according to the professional
fee schedule pursuant to ARM
24.29.1534 or, if no reimbursement
value, ARM
24.29.1523.
(7) Facility billing must be submitted on a
CMS Uniform Billing (UB04) form, including the 837-l form when submitting
electronically.
(8) Hospitals and
ASCs must, on an annual basis, submit to the department data reporting
Medicare, Medicaid, commercial, unrecovered, and workers' compensation claims
reimbursement in a standard form supplied by the department. The department may
in its discretion conduct audits of any facility's financial records to confirm
the accuracy of submitted information.
(9) Medical provider services furnished in an
acute care hospital, ASC, or other facility setting, whether those professional
services are furnished as an employee or as an independent professional, must
be billed separately using the CMS 1500 and must be reimbursed using the
professional fee schedule pursuant to ARM 24.29.1534, except as provided in
(a).
(a) PT, OT, and ST services provided on
an outpatient basis must be billed on a UB04 and reimbursed according to the
facility fee schedule. These reimbursements are excluded from any calculation
of outlier payments. PT, OT, and ST outpatient services may not be billed on
the CMS 1500.
(10)
Facility pharmacy reimbursements are made as follows:
(a) If a facility pharmacy dispenses
prescription drugs to an individual during the course of treatment in the
facility, reimbursement is part of the MS-DRG or APC reimbursement.
(b) If a patient's medications are not
included in the MS-DRG or APC service bundle, the reimbursement will be
according to ARM
24.29.1529.
(11) The following applies to inpatient
services provided at an acute care hospital:
(a) The department may establish the base
rate annually.
(i) The base rate effective
July 1, 2024, is $ 10,141.
(ii) All
prior base rates for services provided starting July 1, 2013, are available on
the department's website.
(b) Payments for inpatient acute care
hospital services must be calculated using the base rate multiplied by the
Montana MS-DRG weight.
(c) If a
service falls outside of the scope of the MS-DRG and is not otherwise listed on
a Montana fee schedule, including new codes not yet adopted, reimbursement for
that service must be 75 percent of that facility's usual and customary charges.
(d) The threshold for outlier
payments is three times the Montana MS-DRG payment amount. If the outlier
threshold is met, the outlier payment must be the MS-DRG reimbursement amount
plus an amount that is determined by multiplying the charges above the
threshold by the sum of 15 percent and the individual hospital's Montana CCR.
(i) For example, if the hospital submits
total charges of $100,000, the MS-DRG reimbursement amount is $25,000, and the
CCR is 0.50, then the resultant calculation for reimbursement is as follows:
The DRG reimbursement amount ($25,000) is multiplied by 3 to set the threshold
trigger ($75,000). The threshold trigger ($75,000) is subtracted from the total
charges ($100,000) resulting in the amount above the trigger ($25,000). The
amount above the trigger ($25,000) is then multiplied by .65 (which is the CCR
of .5 plus .15) to obtain the outlier payment ($16,250). The total payment to
the hospital in this example would be the DRG reimbursement amount ($25,000)
plus the outlier payment ($16,250) = $41,250.
(ii) The department may establish the
inpatient outlier amount annually.
(e) Where an implantable exceeds $10,000 in
cost, hospitals may seek additional reimbursement beyond the normal MS-DRG
payment. Hospitals may seek additional reimbursement by using Montana unique
code MT003. Any implantable that costs less than $10,000 is bundled in the
implantable charge included in the MS-DRG payment.
(i) Any reimbursement for implantables
pursuant to this subsection must be documented by a copy of the invoice for the
implantable (or purchase order if it lists the number of items, the wholesale
price, and the shipping costs) and the operative report. Insurers are subject
to privacy laws concerning disclosure of health or proprietary
information.
(ii) Reimbursement is
set at a total amount that is determined by adding the actual amount paid for
the implantable on the invoice or purchase order for the implantable, plus 15
percent of the actual amount paid for the implantable, plus the handling and
freight cost for the implantable. Handling and freight charges must be included
in the implantable reimbursement and are not to be reimbursed
separately.
(iii) When a hospital
seeks additional reimbursement pursuant to this subsection, the implantable
charge is excluded from any calculation for an outlier payment.
(iv) Because the decision regarding an
implantable is a complex medical analysis, this rule defers to the judgment of
the individual physician and facility to determine the appropriate implantable.
A payer may not reduce the reimbursement when the medical decision is to use a
higher cost implantable.
(f) All facility services provided during an
uninterrupted patient encounter leading to an inpatient admission must be
included in the inpatient stay, except air and ground ambulance services which
are paid separately pursuant to the Montana Ambulance Fee schedule. Air
ambulances whose charter and certification is through the federal Department of
Transportation will be paid at 100 percent of their usual and customary charges
pursuant to federal law.
(g) The
following applies to facility transfers when a patient is transferred for
continuation of medical treatment between two acute care hospitals:
(i) A hospital receiving a patient is paid
the full MS-DRG payment plus any appropriate outliers and add-ons.
(ii) Facility transfers do not include costs
related to transportation of a patient to initially obtain medical care. Such
reimbursements are covered by ARM
24.29.1409.
(12) The following applies to outpatient
services provided at an acute care hospital or an ASC:
(a) The department may establish a base rate
annually.
(i) The base rate effective July 1,
2024, is $130.
(ii) All prior base
rates for services provided starting July 1, 2013, are available on the
department's website.
(b) The department may establish a base rate
annually for ASCs at 75 percent of the hospital outpatient base rate.
(i) The base rate effective July 1, 2024, is
$98.
(ii) All prior base rates for
services provided starting July 1, 2013, are available on the department's
website.
(c) Payments for
outpatient services in a hospital or an ASC are based on the Montana APC
system. A single outpatient visit may result in more than one APC for that
claim. The payment must be calculated by multiplying the base rate times the
APC weight. If an APC code is available, the services must be billed using the
APC code. If the APC weight is not listed or if the APC weight is listed as
null, reimbursement for that service must be paid at 75 percent of the
facility's usual and customary charges. Examples of such services include but
are not limited to laboratory tests and radiology. If a service falls outside
of the scope of the APC and is not otherwise listed on a Montana fee schedule,
reimbursement for that service must be 75 percent of that facility's usual and
customary charges.
(d) CCI and MUE
code edits must be used to determine bundling and unbundling of
charges.
(e) Outpatient medical
services include observation in an outpatient status.
(f) Where an outpatient implantable exceeds
$500 in cost, hospitals or ASCs may seek additional reimbursement beyond the
normal APC payment. In such an instance, the provider may bill using Montana
unique code MT003. Any implantable that costs less than $500 is bundled in the
APC payment.
(i) Any reimbursement for
implantables pursuant to this subsection must be documented by a copy of the
invoice for the implantable (or purchase order if it lists the number of items,
the wholesale price, and the shipping cost) and the operative report. Insurers
are subject to privacy laws concerning disclosure of health or proprietary
information.
(ii) Reimbursement is
set at a total amount that is determined by adding the actual amount paid for
the implantable on the invoice or purchase order for the implantable, plus 15
percent of the actual amount paid for the implantable, plus the handling and
freight cost for the implantable. Handling and freight charges must be included
in the implantable reimbursement and are not to be reimbursed
separately.
(g) The
following applies to patient transfers from an ASC to an acute care hospital:
(i) An ASC transferring a patient is paid the
APC reimbursement.
(ii) The acute
care hospital is paid the MS-DRG or the APC reimbursement, whichever is
applicable.
(iii) Facility
transfers do not include costs related to transportation of a patient to
initially obtain medical care. Such reimbursements are covered by ARM
24.29.1409.
AUTH:
39-71-203, MCA IMP:
39-71-704, MCA
