2023 Colorado Revised Statutes › Title 25.5 - HEALTH CARE POLICY AND FINANCING (§§ 25.5-1-101 — 25.5-11-101) › COLORADO MEDICAL ASSISTANCE ACT (§§ 25.5-4-101 — 25.5-6-2001) › Article 4 - COLORADO MEDICAL ASSISTANCE ACT - GENERAL MEDICAL ASSISTANCE (§§ 25.5-4-101 — 25.5-4-506) › Part 2 - ADMINISTRATION (§§ 25.5-4-201 — 25.5-4-216) › Section 25.5-4-216 - Report on impact of hospital facility fees in Colorado - definitions - steering committee - repeal

(1)
As used in this section:
(a)
"Affiliated with" has the meaning set forth in section
6-20-102 (1)(a)
.
(b)
"Campus" has the same meaning set forth in section
6-20-102 (1)(b)
.
(c)
"CPT code" has the meaning set forth in section
25.5-1-204.7 (1)(d)
.
(d)
"Facility fee" has the meaning set forth in section
6-20-102 (1)(d)
.
(e)
"Health-care provider" has the meaning set forth in section
6-20-102 (1)(f)
.
(f)
"Health system" has the meaning set forth in section
10-16-1303 (9)
.
(g)
"Hospital" has the meaning set forth in section
6-20-102 (1)(j)
.
(h)
"Owned by" has the meaning set forth in section
6-20-102 (1)(m)
.
(i)
"Payer type" has the meaning set forth in section
6-20-102 (1)(n)
.
(j)
"Steering committee" means the steering committee created in subsection (2) of this section.
(2)
There is created in the state department a steering committee to research and report on the impact of outpatient facility fees. The steering committee consists of the following seven members appointed by the governor with relevant expertise in health-care billing and payment policy:
(a)
Two members representing health-care consumers, with at least one of the members representing a health-care consumer advocacy organization;
(b)
One member representing a health-care payer or payers;
(c)
One member representing health-care providers not affiliated with or owned by a hospital or health system or who has independent physician billing expertise;
(d)
One member representing a statewide association of hospitals;
(e)
One member representing a rural, critical access, or independent hospital; and
(f)
The executive director of the department of health care policy and financing, or the executive director's designee.
(3)
(a)
The steering committee shall facilitate the development of a report detailing the impact of outpatient facility fees on the Colorado health-care system, including the impact on consumers, employers, health-care providers, and hospitals. In developing various aspects of the report required in this section, the steering committee shall work with independent third parties to conduct related research and analysis necessary to identify and evaluate the impact of outpatient facility fees.
(b)
The steering committee shall prepare a preliminary version of the report on or before August 1, 2024, unless more time is required, and a final report on or before October 1, 2024, that must be submitted to the house of representatives health and insurance committee and the senate health and human services committee, or their successor committees.
(4)
(a)
For purposes of developing the report, the steering committee, with administrative support from the state department, may:
(I)
Select third-party contractors to assist in researching and creating the report, with an appropriation made to the state department for such purpose;
(II)
Develop the format, scope, and templates for requests for information;
(III)
Review drafts, provide feedback, and finalize the report;
(IV)
Answer technical questions from third-party contractors; and
(V)
Consult with external stakeholders.
(b)
The steering committee, state department, and any third-party contractors engaged in the development of the report are encouraged to use both primary and secondary sources and research, where possible, and, to the extent feasible, ensure the report is well-informed by the perspectives of diverse stakeholders. The steering committee shall work only with third-party contractors that are already approved as one of the state department's project-based contracts.
(c)
To the extent practicable, evaluation and analysis performed for the report must attempt to leverage Colorado-specific data sources and publicly available national data and research.
(5)
The report must identify and evaluate:
(a)
Payer reimbursement and payment policies for outpatient facility fees across payer types, including insights, where available, into changes over time, as well as provider billing guidelines and practices for outpatient facility fees across provider types, including insights, where available, into changes made over time;
(b)
Payments for outpatient facility fees, including insights into the associated care across payer types;
(c)
Coverage and cost-sharing provisions for outpatient care services associated with facility fees across payers and payer types;
(d)
Denied facility fee claims by payer type and provider type;
(e)
The impact of facility fees and payer coverage policies on consumers, small and large employers, and the medical assistance program;
(f)
The impact of facility fees and payer coverage policies on the charges for health-care services rendered by independent health-care providers, including a comparison of professional fee charges and facility fee charges; and
(g)
The charges for health-care services rendered by health-care providers affiliated with or owned by a hospital or health system, and including a comparison of professional fee and facility fee charges.
(6)
The report must include an analysis of:
(a)
Data from the Colorado all-payer health claims database as reported under DSG14, including, at a minimum:
(I)
The number of patient visits for which facility fees were charged, including, to the extent possible, a breakdown of which visits were in network and which were out of network;
(II)
To the extent possible, the number of patient visits for which the facility fees were charged out of network and the professional fees were charged in network for the same outpatient service;
(III)
The total allowed facility fee amounts billed and denied;
(IV)
The top ten most frequent CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, for which facility fees were charged;
(V)
The top ten CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, with the highest total allowed amounts from facility fees;
(VI)
The top ten CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, for which facility fees are charged with the highest member cost sharing; and
(VII)
The total number of facility fee claim denials, by site of service;
(b)
Data from hospitals and health systems, which data shall be provided to the steering committee, including:
(I)
The number of patient visits for which facility fees were charged;
(II)
The total revenue collected in facility fees;
(III)
A description of the most frequent health-care services for which facility fees were charged and net revenue received for each such service;
(IV)
A description of health-care services that generated the greatest amount of gross facility fee revenue and net revenue received for each such service; and
(V)
Data from off-campus health-care providers that are affiliated with or owned by a hospital or health system, including:
(A)
Historic and current business names and addresses;
(B)
Historic and current tax identification numbers and national provider identifiers;
(C)
Health-care provider acquisition or affiliation date;
(D)
Facility fee billing policies, including whether any changes were made to such policies before or after the acquisition or affiliation date; and
(E)
The top ten CPT codes, revenue codes, or combination thereof, at the state department's discretion, for which a facility fee is billed and the professional fee amount for the same service;
(c)
Data, if available, from the state department, the division of insurance, and commercial payers, including:
(I)
The payment policy each payer uses for payment of facility fees for network products, including any changes that were made to such policies within the last five years;
(II)
A list of common procedures associated with facility fees;
(III)
Each payer's network product names;
(IV)
Paid aggregate facility fee billings from outpatient providers and the associated number of facility fee claims, broken down by hospital or health system; and
(V)
A description of the estimated impact of facility fees on premium rates, out-of-network claims, member cost sharing, and employer costs;
(d)
Data from independent health-care providers that are not affiliated with or owned by a hospital or health system, including:
(I)
Historic and current business names and addresses;
(II)
Historic and current tax identification numbers and national provider identifiers;
(III)
Facility fee billing policies, including whether any changes were made to such policies in the past five years; and
(IV)
Where applicable, the top ten CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, for which a facility fee is billed and the professional fee amount for the same service;
(e)
The impact of facility fees and payer coverage policies on the Colorado healthcare affordability and sustainability enterprise, created in section
25.5-4-402.4
, the medicaid expansion, uncompensated care, and undercompensated care;
(f)
The impact of facility fees on access to care, including specialty care, primary care, and behavioral health care; integrated care systems; health equity; and the health-care workforce; and
(g)
A description of the way in which health-care providers may be paid or reimbursed by payers for outpatient health-care services, with or without facility fees, that explores any legal and historical reasons for split billing between professional and facility fees at:
(I)
On-campus locations;
(II)
Off-campus locations by health-care providers affiliated with or owned by a hospital or health system; and
(III)
Locations by independent health-care providers not affiliated with or owned by a hospital system.
(7)
To the extent feasible, data analyzed for purposes of subsection (6) of this section must be sourced from 2014 through 2022, as determined by the steering committee and third-party contractors, and shall be disaggregated by:
(a)
Year;
(b)
Hospital or health system, where applicable;
(c)
Type of service;
(d)
Facility site type, including on- or off-campus; and
(e)
Payer.
(8)
The steering committee may include in the report information received in accordance with this section; except that the steering committee shall not share publicly any information submitted to the steering committee that is confidential, is proprietary, contains trade secrets, or is not a public record pursuant to part 2 of article
72
of title
24
except in aggregated and de-identified form.
(9)
The data described in this section must be sought in a form and manner determined by the steering committee, state department, or third-party contractors to facilitate submission of information. The steering committee shall seek to exhaust existing data sources before making additional requests for information for purposes of the report, and every effort must be made to minimize the number of data requests. The report must include a description of which entities were contacted for information and the outcome of each request.
(10)
A statewide association of hospitals may also provide data specified in subsection (6)(b) of this section to the steering committee.
(11)
This section is repealed, effective January 1, 2025.
Added by 2023 Ch. 277,§ 4, eff. 5/30/2023.