Fed Regist. 1998 Oct 13;63(197):54756-65.
This document proposes to amend VA's medical regulations concerning collection or recovery by VA for medical care or services provided or furnished to a veteran: For a non-service connected disability for which the veteran is entitled to care (or the payment of expenses of care) under a health-plan contract; For a non-service connected disability incurred incident to the veteran's employment and covered under a worker's compensation law or plan that provides reimbursement or indemnification for such care and services; or For a non-service connected disability incurred as a result of a motor vehicle accident in a State that requires automobile accident reparations insurance. Previously, by statute VA was authorized to charge "reasonable costs" for such care or services. However, amended statutory provisions now authorize VA to charge "reasonable charges." Accordingly, this document proposes to establish methodology for charging "reasonable charges" consistent with the statutory amendment. Under the proposal, the charges billed using this methodology, as appropriate, would consist of inpatient facility charges, skilled nursing facility/sub-acute inpatient facility charges, outpatient facility charges, physician charges, and non-physician provider charges. Reasonable charges for outpatient dental care and prescription drugs not administered during treatment would continue to be billed using the existing cost-based methodology. Pursuant to statutory authority, VA has the right to recover or collect the charges from a third party to the extent that a provider of the care or services would be eligible to receive payment therefor from that third party if the care or services had not been furnished by a department or agency of the United States. With respect to a third-party payer liable under a health plan contract, consistent with the statutory authority, the third-party payer would have the option of paying to the extent of its coverage, either the billed charges or the amount the third-party payer demonstrates it would pay for care or services furnished by providers other than entities of the United States for the same care or services in the same geographic area. Using the methodology in this proposed rule, the data for calculating actual amounts for the various inpatient facility charges, skilled nursing facility/sub-acute inpatient facility charges, outpatient facility charges, and physician charges at individual VA facilities for the period August 1998 through September 1999 are set forth in a companion document published in the "Notices" section of this issue of the Federal Register. Also, under the proposal, the regulations would be clarified to state specifically that billing methodology based on costs will continue to be applied to establish charges for medical care furnished in error or on tentative eligibility, furnished in a medical emergency, furnished to certain beneficiaries of the Department of Defense or other Federal agencies, furnished to pensioners of allied nations, and furnished to military retirees with chronic disability.
本文件提议修订退伍军人事务部（VA）关于VA对向退伍军人提供的医疗护理或服务进行收费或追讨费用的医疗法规：针对退伍军人根据健康计划合同有权获得护理（或护理费用支付）的非与服役相关的残疾；针对退伍军人在就业过程中发生且根据工人赔偿法或计划承保的非与服役相关的残疾，该法或计划为此类护理和服务提供报销或赔偿；或针对在要求汽车事故赔偿保险的州因机动车事故而导致的非与服役相关的残疾。此前，根据法规，VA被授权对这类护理或服务收取“合理成本”。然而，修订后的法规条款现在授权VA收取“合理费用”。因此，本文件提议制定与法规修订相一致的收取“合理费用”的方法。根据该提议，酌情使用此方法开具的费用账单将包括住院设施费用、熟练护理设施/亚急性住院设施费用、门诊设施费用、医生费用以及非医生提供者费用。门诊牙科护理和治疗期间未给药的处方药的合理费用将继续使用现有的基于成本的方法开具账单。根据法定授权，VA有权从第三方追讨或收取费用，前提是如果护理或服务不是由美国的部门或机构提供，护理或服务的提供者本应有资格从该第三方获得为此类护理或服务的付款。对于根据健康计划合同负有责任的第三方付款人，根据法定授权，第三方付款人可以选择在其承保范围内支付账单费用，或者支付第三方付款人证明其将为美国以外实体在同一地理区域提供相同护理或服务而支付的金额。使用本拟议规则中的方法，计算1998年8月至1999年9月期间各VA设施的各种住院设施费用、熟练护理设施/亚急性住院设施费用、门诊设施费用和医生费用实际金额的数据载于本期《联邦公报》“通知”部分发布的一份配套文件中。此外，根据该提议，法规将得到澄清，具体规定基于成本的计费方法将继续用于确定因错误提供或基于暂定资格提供的医疗护理、在医疗紧急情况下提供的医疗护理、提供给国防部或其他联邦机构的某些受益人的医疗护理、提供给盟国养老金领取者的医疗护理以及提供给患有慢性残疾的军事退休人员的医疗护理的费用。
