Current through Reg. 49, No. 38; September 20, 2024
(a) Applicability of this section is as
follows.
(1) This section applies to medical
services provided in an outpatient acute care hospital on or after March 1,
2008.
(2) This section does not
apply to:
(A) professional medical services
billed by a provider not employed by the hospital, except for a surgical
implant provider as described in this section; or
(B) medical services provided through a
workers' compensation health care network certified pursuant to Insurance Code
Chapter 1305, except as provided in Insurance Code Chapter 1305.
(b) Definitions for
words and terms, when used in this section, shall have the following meanings,
unless clearly indicated otherwise.
(1)
"Acute care hospital" means a health care facility appropriately licensed by
the Texas Department of State Health Services that provides inpatient and
outpatient medical services to patients experiencing acute illness or
trauma.
(2) "Implantable" means an
object or device that is surgically:
(A)
implanted,
(B) embedded,
(C) inserted,
(D) or otherwise applied, and
(E) related equipment necessary to operate,
program and recharge the implantable.
(3) "Medicare payment policy" means
reimbursement methodologies, models, and values or weights including its
coding, billing, and reporting payment policies as set forth in the Centers for
Medicare and Medicaid Services (CMS) payment policies specific to
Medicare.
(4) "Outpatient" means
the patient is not admitted for inpatient or residential care. Outpatient
medical services includes observation in an outpatient status provided the
observation period complies with Medicare policies.
(5) "Surgical implant provider" means a
person that arranges for the provision of implantable devices to a health care
facility and that then seeks reimbursement for the implantable devices provided
directly from an insurance carrier.
(c) A surgical implant provider is subject to
Chapter 133 of this title and is considered a health care provider for purposes
of this section and the sections in Chapter 133 of this title (relating to
Benefits--Medical Benefits).
(d)
For coding, billing, reporting, and reimbursement of health care covered in
this section, Texas workers' compensation system participants shall apply
Medicare payment policies in effect on the date a service is provided with any
additions or exceptions specified in this section, including the following
paragraphs.
(1) Specific provisions contained
in the Texas Labor Code or the Texas Department of Insurance, Division of
Workers' Compensation (Division) rules, including this chapter, shall take
precedence over any conflicting provision adopted or utilized by the CMS in
administering the Medicare program.
(2) Independent Review Organization decisions
regarding medical necessity made in accordance with Labor Code §
413.031
and § 133.308 of this title (relating to MDR by Independent Review
Organizations), which are made on a case-by-case basis, take precedence in that
case only, over any Division rules and Medicare payment policies.
(3) Whenever a component of the Medicare
program is revised and effective, use of the revised component shall be
required for compliance with Division rules, decisions, and orders for services
rendered on and after the effective date, or after the effective date or the
adoption date of the revised Medicare component, whichever is later.
(e) Regardless of billed amount,
reimbursement shall be:
(1) the amount for
the service that is included in a specific fee schedule set in a contract that
complies with the requirements of Labor Code §
413.011;
or
(2) if no contracted fee
schedule exists that complies with Labor Code §
413.011,
the maximum allowable reimbursement (MAR) amount under subsection (f) of this
section, including any applicable outlier payment amounts and reimbursement for
implantables.
(3) If no contracted
fee schedule exists that complies with Labor Code §
413.011,
and an amount cannot be determined by application of the formula to calculate
the MAR as outlined in subsection (f) of this section, reimbursement shall be
determined in accordance with §
134.1 of
this title (relating to Medical Reimbursement).
(f) The reimbursement calculation used for
establishing the MAR shall be the Medicare facility specific amount, including
outlier payment amounts, determined by applying the most recently adopted and
effective Medicare Outpatient Prospective Payment System (OPPS) reimbursement
formula and factors as published annually in the Federal
Register. The following minimal modifications shall be applied.
(1) The sum of the Medicare facility specific
reimbursement amount and any applicable outlier payment amount shall be
multiplied by:
(A) 200 percent;
unless
(B) a facility or surgical
implant provider requests separate reimbursement in accordance with subsection
(g) of this section, in which case the facility specific reimbursement amount
and any applicable outlier payment amount shall be multiplied by 130
percent.
(2) When
calculating outlier payment amounts, the facility's total billed charges shall
be reduced by the facility's billed charges for any item reimbursed separately
under subsection (g) of this section.
(g) Implantables, when billed separately by
the facility or a surgical implant provider in accordance with subsection
(f)(1)(B) of this section, shall be reimbursed at the lesser of the
manufacturer's invoice amount or the net amount (exclusive of rebates and
discounts) plus 10 percent or $1,000 per billed item add-on, whichever is less,
but not to exceed $2,000 in add-on's per admission.
(1) A facility or surgical implant provider
billing separately for an implantable shall include with the billing a
certification that the amount billed represents the actual cost (net amount,
exclusive of rebates and discounts) for the implantable. The certification
shall include the following sentence: "I hereby certify under penalty of law
that the following is the true and correct actual cost to the best of my
knowledge."
(2) A carrier may use
the audit process under §
133.230
of this title (relating to Insurance Carrier Audit of a Medical Bill) to seek
verification that the amount certified under paragraph (1) of this subsection
properly reflects the requirements of this subsection. Such verification may
also take place in the Medical Dispute Resolution process under §
133.307 of
this title (relating to MDR of Fee Dispute), if that process is properly
requested, notwithstanding 133.307(d)(2)(B) of this title.
(3) Nothing in this rule precludes a health
care facility or insurance carrier from utilizing a surgical implant provider
to arrange for the provision of implantable devices. Implantables provided by a
surgical implant provider shall be reimbursed according to this
subsection.
(h) For
medical services provided in an outpatient acute care hospital, but not
addressed in the Medicare payment policies as outlined in subsections (f)(1) or
(f)(2) of this section, and for which Medicare reimburses using other Medicare
fee schedules, reimbursement shall be made using the applicable Division Fee
Guideline in effect for that service on the date the service was
provided.
(i) Notwithstanding
Medicare payment policies, whenever Medicare requires a specific setting for a
service, that restriction shall apply, unless an alternative setting and
payment has been approved through the Division's preauthorization, concurrent
review, or voluntary certification of health care process.
(j) A preauthorization request may be
submitted for an alternative facility setting only if an agreement has already
been reached and a copy of the signed agreement is filed as a part of the
preauthorization request. Copies of the agreement shall be kept by both
parties. This agreement does not constitute a voluntary network established in
accordance with Labor Code §
413.011(d-1).
(1) The agreement between the insurance
carrier and the party that requested the alternative facility setting must be
in writing, in clearly stated terms, and include:
(A) the reimbursement amount;
(B) a description of the services to be
performed under the agreement;
(C)
any other provisions of the agreement; and
(D) names of the entities, titles, and
signatures of both parties, and names, titles, signatures with dates of the
persons signing the agreement.
(2) An agreement for an alternative facility
setting may be revised during or after preauthorization by written agreement of
the insurance carrier and the party that requested the alternative facility
setting.
(3) Upon request of the
Division, all agreement information shall be submitted in the form and manner
prescribed by the Division.
(k) If a court of competent jurisdiction
holds that any provision of this section is inconsistent with any statutes of
this state, are unconstitutional, or are invalid for any reason, the remaining
provisions of this section shall remain in full effect.
