Source: http://thefederalregister.com/2011/06/24/2011-15854.html
Timestamp: 2019-08-17 23:47:12
Document Index: 74113829

Matched Legal Cases: ['art 220', '§ 17', '§ 17', '§ 17', '§ 17', '§ 17', '§ 17', '§ 17', '§ 17', '§ 17', 'art 403', 'arts 101', 'art 11', 'art 900', 'art 1']

Federal Register | Reimbursement Offsets for Medical Care or Services
RIN 2900-AN55
SUMMARY: This document amends the regulations of the Department of Veterans Affairs (VA) concerning the reimbursement of medical care and services delivered to veterans for nonservice-connected conditions. This rule applies in situations where third-party payers are required to reimburse VA for costs related to care provided by VA to a veteran covered under the third-party payer's plan. This final rule adds a new section barring offsets by third-party payers and requires that third-party payers submit a request for a refund for claims when there is an alleged overpayment.
DATES: Effective Date:July 25, 2011.
FOR FURTHER INFORMATION CONTACT: Anthony Norris, Program Analyst, Business Operations, Chief Business Office (168), Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 461-1593. (This is not a toll free number.)
In a document published in theFederal Registeron October 8, 2010 (75 FR 62348), we proposed to amend VA's regulations concerning the reimbursement of medical care and services delivered to veterans for nonservice-connected conditions to address reimbursement offsets. In the proposed rule we explained that the changes are consistent with regulations promulgated by the Department of Defense (DoD) in 32 CFR Part 220. DoD's collection statute, 10 U.S.C. 1095, is similar to VA's collection statute, 38 U.S.C. 1729. We intended that the proposed rule would clarify VA's interpretation of the statute. The purpose of the proposed rule is to proscribe offsetting by third-party payers, provide clarity and uniformity in how third-party payers interact with both VA and DOD, and eliminate disruptions to VA accounting, collections, and account receivables. We provided a 60-day comment-period, which ended on December 7, 2010. We received 3 comments, one from the general public and two from within the health insurance industry.
This commenter's questions suggest a possible misunderstanding concerning the scope of our proposal. We did not propose to establish an entirely new process for third parties seeking reimbursement from VA for alleged overpayments. Rather, we proposed to clarify the rules regarding VA collections and to require third-party payers to present any alleged overpayment claim to VA rather than unilaterally offsetting money owed to VA. To further clarify the purpose of this rulemaking, we have changed the heading for § 17.106 from “Third-party claims for refunds based on amounts previously paid to the Department of Veterans Affairs (overpayments)” to “VA collection rules; third-party payers.” We made no further changes to the rule based upon these comments.
Two commenters from within the health insurance industry asserted that the rule, in particular the language in § 17.106(a)(1), is not authorized by 38 U.S.C. 1729. The commenters' position is that VA providers must meet the same timely filing rules insurers require of commercial or other providers or members in their coverage contracts, and argue that the rule would override insurers own time limits for filing claims applicable to providers. We disagree.
Although beneficiaries of health insurers generally must file a claim for reimbursement within a specified period of time in order to seek reimbursement, the statutory authority granted to VA by Congress does not place such a time limit on VA's right to seek reimbursement from third-parties. This is clearly set forth in 38 U.S.C. 1729(f), which states that “[n]o provision of any contract or other agreement, shall operate to prevent recovery or collection by the United States under this section or with respectto care or services furnished under section 1784 of this title.” Therefore, we make no changes based on this comment.
The commenters' objections also seem to be that the statute gives the right of a cause of action to the “United States” and not specifically to VA. We disagree. We interpret “United States” as used by Congress in section 1729 to mean an action by the Federal government on behalf of a Federal department or agency. This final rule implements that interpretation in § 17.106(c)(1).
One commenter requested that VA revise § 17.106(c)(4), which prohibits a third-party payer from offsetting other claims due to the VA in order to recover an overpayment. The commenter recommended instead that the rule state that VA facilities and insurers may agree to permit offsets in lieu of a separate appeal and adjudication process. Similarly, another commenter stated that when a third-party offsets overpayments against amounts otherwise due a VA facility, the third-party is treating the VA facility like any other health care provider. The commenter asserted that VA has no legal right to seek a higher standing. We do not agree.
Similar comments on this topic appear to dispute the range of services for which VA may seek reimbursement. A commenter argued that since anexclusive provider organization (EPO) would not generally pay claims submitted by an out-of-network private provider, the EPO is not required under the statute to pay an out-of-network VA facility. The commenter asserted that the proposed rule, which noted that a third-party payer must pay only to the extent covered by the payer's plan, supported the commenter's view.
Administrative practice and procedure, Alcohol abuse, Alcoholism, Claims, Day care, Dental health, Drug abuse, Foreign relations, Government contracts, Grant programs-health, Government programs-veterans, Health care, Health facilities, Health professions, Health records, Homeless, Medical and dental schools, Medical devices, Medical research, Mental health programs, Nursing home care, Veterans.
Dated: June 21, 2011. Robert C. McFetridge, Director, Office of Regulation Policy and Management, Office of the General Counsel, Department of Veterans Affairs.
§ 17.106 [Redesignated as § 17.107]
2. Redesignate § 17.106 as § 17.107. 3. Add new § 17.106 before the undesignated center heading “Disciplinary Control of Beneficiaries Receiving Hospital, Domiciliary or Nursing Home Care” to read as follows:
(a)(1)General rule.VA has the right to recover or collect reasonable charges from a third-party payer for medical care and services provided for a nonservice-connected disability in or through any VA facility to a veteran who is also a beneficiary under the third-party payer's plan. VA's right to recover or collect is limited to the extentthat the beneficiary or a nongovernment provider of care or services would be eligible to receive reimbursement or indemnification from the third-party payer if the beneficiary were to incur the costs on the beneficiary's own behalf.
(2)Definitions.For the purposes of this section:
Automobile liability insurancemeans insurance against legal liability for health and medical expenses resulting from personal injuries arising from operation of a motor vehicle. Automobile liability insurance includes:
Health-plan contractmeans any plan, policy, program, contract, or liability arrangement that provides compensation, coverage, or indemnification for expenses incurred by a beneficiary for medical care or services, items, products, and supplies. It includes but is not limited to:
Medicare supplemental insurance planmeans an insurance, medical service or health-plan contract primarily for the purpose of supplementing an eligible person's benefit under Medicare. The term has the same meaning as “Medicare supplemental policy” in section 1882(g)(1) of the Social Security Act (42 U.S.C. 1395,et seq.) and 42 CFR part 403, subpart B.
No-fault insurancemeans an insurance contract providing compensation for medical expenses relating to personal injury arising from the operation of a motor vehicle in which the compensation is not premised on who may have been responsible for causing such injury. No-fault insurance includes personal injury protection and medical payments benefits in cases involving personal injuries resulting from operation of a motor vehicle.
Participating provider organizationmeans any arrangement in a third-party payer plan under which coverage is limited to services provided by a select group of providers who are members of the PPO or incentives (for example, reduced copayments) are provided for beneficiaries under the plan to receive health care services from the members of the PPO rather than from other providers who, although authorized to be paid, are not included in the PPO. However, a PPO does not include any organization that is recognized as a health maintenance organization.
Third-party payermeans an entity, other than the person who received the medical care or services at issue (first party) and VA who provided the care or services (second party), responsible for the payment of medical expenses on behalf of a person through insurance, agreement or contract. This term includes, but is not limited to the following:
(b)Calculating reasonable charges.(1) The “reasonable charges” subject to recovery or collection by VA under this section are calculated using the applicable method for such charges established by VA in 38 CFR 17.101.
(c)VA's right to recover or collect is exclusive.The only way for a third-party payer to satisfy its obligation under this section is to pay the VA facility or other authorized representative of the United States. Payment by a third-party payer to the beneficiary does not satisfy the third-party's obligation under this section.
(3) The remedies authorized for collection of indebtedness due the United States under 31 U.S.C. 3701,et seq.,4 CFR parts 101 through 104, 28 CFR part 11, 31 CFR part 900, and 38 CFR part 1, are available to effect collections under this section.
(d)Assignment of benefits or other submission by beneficiary not necessary.The obligation of the third-party payer to pay is not dependentupon the beneficiary executing an assignment of benefits to the United States. Nor is the obligation to pay dependent upon any other submission by the beneficiary to the third-party payer, including any claim or appeal. In any case in which VA makes a claim, appeal, representation, or other filing under the authority of this part, any procedural requirement in any third-party payer plan for the beneficiary of such plan to make the claim, appeal, representation, or other filing must be deemed to be satisfied. A copy of the completed VA Form 10-10EZ or VA Form 10-10EZR that includes a veteran's insurance declaration will be provided to payers upon request, in lieu of a claimant's statement or coordination of benefits form.
(e)Preemption of conflicting State laws and contracts.Any provision of a law or regulation of a State or political subdivision thereof and any provision of any contract or agreement that purports to establish any requirement on a third-party payer that would have the effect of excluding from coverage or limiting payment for any medical care or services for which payment by the third-party payer under 38 U.S.C. 1729 or this part is required, is preempted by 38 U.S.C. 1729(f) and shall have no force or effect in connection with the third-party payer's obligations under 38 U.S.C. 1729 or this part.
(f)Impermissible exclusions by third-party payers.(1)Statutory requirement.Under 38 U.S.C. 1729(f), no provision of any third-party payer's plan having the effect of excluding from coverage or limiting payment for certain care if that care is provided in or through any VA facility shall operate to prevent collection by the United States.
(2)General rules.The following are general rules for the administration of 38 U.S.C. 1729 and this part, with examples provided for clarification. The examples provided are not exclusive. A third-party payer may not reduce, offset, or request a refund for payments made to VA under the following conditions:
(i) Express exclusions or limitations in third-party payer plans that are inconsistent with 38 U.S.C. 1729 are inoperative. For example, a provision in a third-party payer's plan that purports to disallow or limit payment for services provided by a government entity or paid for by a government program (or similar exclusion) is not a permissible ground for refusing orreducing third-party payment.
(g)Records.Pursuant to 38 U.S.C. 1729(h), VA shall make available for inspection and review to representatives of third-party payers, from which the United States seeks payment, recovery, or collection under 38 U.S.C. 1729, appropriate health care records (or copies of such records) of patients. However, the appropriate records will be made available only for the purposes of verifying the care and services which are the subject of the claim(s) for payment under 38 U.S.C. 1729, and for verifying that the care and services met the permissible criteria of the terms and conditions of the third-party payer's plan. Patient care records will not be made available under any other circumstances to any other entity. VA will not make available to a third-party payer any other patient or VA records.