24.29.1432    FACILITY SERVICE RULES AND RATES FOR SERVICES PROVIDED FROM DECEMBER 1, 2008 THROUGH JUNE 30, 2013

(1) The department adopts the fee schedules provided by this rule to determine the reimbursement amounts for medical services provided at a facility when a person is discharged on or after December 1, 2008. An insurer is obligated to pay the fee provided by the fee schedules for a service, even if the billed charges are 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, available online via the Internet at�http://erd.dli.mt.gov/workers-comp-claims-assistance/medical-regulations/montana-facility-fee-schedule/7-erd/workers-comp-regulations/267-montana-facility-fee-schedule.html, are comprised of the following elements:

(a) The Montana Hospital Inpatient Services MS-DRG Reimbursement Fee Schedule, based on CMS version 26;

(b) The Montana Hospital Outpatient and ASC Fee Schedule Organized by APC;

(c) The Montana Hospital Outpatient and ASC Fee Schedule Organized by CPT/HCPCS;

(d) The Montana Ambulance Fee Schedule;

(e) The Montana CCI Code Edits Listing;

(f) The Montana RCC and other Montana RCC-based Calculations;

(g) The Montana Status Indicator (SI) Codes; and

(h) The base rates and conversion formulas established by the department.

(2) The application of the base rate depends on the date the medical services are provided.

(3) Critical access hospitals and medical assistance facilities are reimbursed at 100 percent of that facility's usual and customary charges.

(4) Any services provided by a type of facility not explicitly addressed by this rule must be paid at 75 percent of its 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 at 75 percent of a facility's usual and customary charges.

(7) Facility billing must be submitted on a CMS Uniform Billing (UB-04) form or CMS 1500 form, including the 837-l and 837-P 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) Individual medical providers who furnish professional services in a hospital, ASC, or other facility setting must bill insurers separately and must be reimbursed using the nonfacility fee schedule. Those reimbursements are excluded from any calculation of outlier payments.

(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 75 percent of the facility's usual and customary charges.

(11)�The following applies to inpatient services provided at an acute care hospital:

(a)�The department may establish the base rate annually.

(i)�Effective December 1, 2008, the base rate is $7,735.

(b)�Payments for inpatient acute care hospital services must be calculated using the base rate multiplied by the Montana MS-DRG weight.�For example, if the MS-DRG weight is 0.5, the amount payable is $3,867.50, which is the base rate of $7,735 multiplied by 0.5.

(c)�If a service falls outside of the scope of the MS-DRG 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)�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 operating RCC.

(i)�For example, if the hospital submits total charges of $100,000, the MS-DRG reimbursement amount is $25,000, and the RCC 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 RCC 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.�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.�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, plus the handling and freight cost for the implantable, plus 15 percent of the actual amount paid 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.

(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 transferring a patient is paid as follows:�The MS-DRG reimbursement amount is divided by the geometric mean number of days duration listed for the MS-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 geometric mean 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.

(ii)�A hospital receiving a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons.

(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.

(12)�The following applies to outpatient services provided at an acute care hospital or an ASC:

(a)�The department may establish the base rate for outpatient service at acute care hospitals annually.

(i)�Effective December 1, 2008, the base rate for hospital outpatient services is $105.

(b)�The department may establish the base rate for ASCs annually.

(i)�Effective December 1, 2008, the base rate for ASCs is $79, which is 75 percent of the hospital base rate.

(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 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, radiology, and therapies.�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 code edits must be used to determine bundling and unbundling of charges. No other clinical editing is allowed 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 CPT code L 8699, and the status indicator code "N" may not be used by a payer to determine the amount of the payment. 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. 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, plus the handling and freight cost for the implantable, plus 15 percent of the actual amount paid 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.

History: 39-71-203, MCA; IMP, 39-71-203, 39-71-704, MCA; NEW, 2008 MAR p. 2490, Eff. 12/1/08; AMD, 2013 MAR p. 1185, Eff. 7/12/13.