Medical care collection or recovery. Department of Veterans Affairs. Final rule.

This document amends VA's medical regulations concerning collection or recovery by VA for medical care or services provided or furnished to a veteran: (1) For a non-service connected disability for which the veteran is entitled to care (or the payment of expenses of care) under a healthplan contract; (2) 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 (3) 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 establishes methodology for charging "reasonable charges" consistent with the statutory amendment. The charges billed using this methodology, as appropriate, 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 will 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 therefore 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 continues to 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. Also, the regulations are 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.