briefing: basic policies

2010 UBO/UBU Conference

Health Budgets & Financial Policy Briefing: Basic Policies

Date: 25 March 2010

Time: 1110-1200

2010 UBO/UBU ConferenceTurning Knowledge Into Action

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Objectives

Recognize the differences between statutes (laws), regulations, policies, directives, instructions, and manuals

Identify those policies that directly affect how you do your job


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Statutes (Laws) v. Regulations

Statutes (Laws)

Passed by the legislative branch– United States Congress– State legislatures

Provide broad basis of “do’s and don’ts”– Usually so broad, they need implementing

“guidance”


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Regulations

Developed by executive branch agency responsible for that subject matter

Help clarify the intent of the law– Examples

Medicare law– Regulation promulgated by CMS (part of DHHS)

Military health care– Regulation promulgated by TMA (part of DoD)


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Regulations – Stages

Notices – Announcements to the public– MAC rates– DD Form 2569

Proposed Rules– Implementing new law– Changing existing regulations– Comment Period


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Regulations – Stages

Final Rules– Summarize comments from proposed rules– Have the force of law– Interim Final Rules may be effective immediately

with Comment Period


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Policies

Developed as needed Further interpretation of a regulation


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HA Policies

Permanent Prohibition Against Requiring Certain Injured Members to Pay for Meals Provided by Military

Treatment Facilities

(FY NDAA 09 – 4 Feb 2009)

MTFs must furnish meals at no cost to military members receiving inpatient or outpatient services for an injury, illness, or disease caused while in combat

Includes medical recuperation or therapy or other continuous care

2010 UBO/UBU ConferenceTurning Knowledge Into Action HA Policies

DHP Accounts Receivable Policy

(2 May 2008) Policy to recognize, collect, and report accounts

receivable Goal: Improve the accuracy of financial statements and

prepare DHP-funded activities for audit Compliance by each Financial Statement Reporting

Entity (FSRE) required by 30 September 2008– Delayed until 30 September 2009

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Policy Guidance for Provision of Medical Care Provided to DoD Civilian Employees Injured or Wounded While

Forward Deployed in Support of Hostilities (24 September 07)

DoD Civilians who become ill, injured, wounded while

forward deployed are eligible for medical evacuation and treatment in MTFs as if they were military personnel

Worker’s Compensation – employee is treated at no cost

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HA Policy 08-007Policy for Billing and Collections for

TPCP, MSA, MAC in MTFs

Billing and collection activities may be performed by MTF personnel, other Government personnel, contract personnel, or any combination of personnel

Billing and collection activities may be performed at the MTF, other Government location, contract location, or any combination of locations

MTFs are not restricted to using TPOCS or the MSA module in the Composite Health Care System

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HA Policy 08-007Policy for Billing and Collections for

TPCP, MSA, MAC in MTFs

The Services must provide management data to TMA UBO on request

The Services should implement best business practices to manage their collections programs and to meet TMA UBO reporting requirements

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HA Policy 08-002

Policy for Billing for Care Furnished by Military Treatment Facilities to Federal Employees for On-the-Job Injuries

and for Occupational Health (8 April 2008)

Bill NAF at IAR for Occupational Health and OTJ injury Do not bill DoD when furnishing Occupational Health or

care for OTJ to appropriated fund DoD employees Bill all other federal agencies at IAR for Worker’s Comp Bill employees for all other care unless they are a

beneficiary

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HA PoliciesHA Policy 07-026

Policy for Billing Non-Department of Defense Beneficiary Newborns

DoD has a legal obligation to recover reasonable cost of health care services to non-DoD beneficiaries

MTFs are to bill for newborns of family member daughters and for certain former Service members– Bill for services from time of birth to time of discharge– Use full reimbursement rate


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HA Policies

HA Policy 06-010

HIPAA Security Compliance

Implements DHHS Security Standards HIPAA Security charges organizations to protect e-PHI

against any reasonably anticipated threats or hazards to the security and integrity of the information

Protect against any reasonably anticipated uses or disclosures that are not permitted under HIPAA

Retain compliance documentation for six years


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HA PoliciesHA Policy 05-020

Policy for Cosmetic Surgery Proceduresin the MHS

To accomplish wartime mission, we need specialists skilled in reconstructive cosmetic surgery

– These specialists need to perform surgery regularly to keep up their skills/certification

– Cosmetic procedures are authorized in direct care system under limited circumstances

Only privileged staff/residents in plastic surgery, otorhinolaryngology, ophthalmology, dermatology, oral-maxillofacial surgery may perform cosmetic surgery

– 20% of their practice


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HA Policies

HA Policy 05-020Policy for Cosmetic Surgery Procedures

in the MHS

Civilians providers may only perform if they are employed full-time by MTF

Cosmetic surgery performed “space available”– May not exceed 20% of the physician’s case load

Only for TRICARE-eligible beneficiaries– Active duty must have written permission from unit

commander All patients must pay

– Complications are not a covered benefit


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HA Policies

HA Policy 04-028Termination of Subsistence Surcharge for Uniformed

Services Personnel in MTFs

Do not collect daily subsistence surcharge from Active Duty or retired members hospitalized for medical care


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HA Policies

Compliance Plan Implementation Policy

(28 February 2002)

“The adoption and implementation of compliance programs significantly advances the prevention of fraud, while furthering the mission of providing quality care to patients”

MTFs and other DoD-designated billing activities must establish and comply with compliance guidelines– Establish a compliance plan focused on coding and billing

ethical conduct– Perform a compliance audit at least quarterly


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HA Policies


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DoD Issuances


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Instructions (DoDIs)

Implement policies– Prescribe how to carry out a policy– Include assigning responsibilities


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DoDI 6015.23 - Delivery Of Healthcare At Military Treatment Facilities: Foreign Service Care; Third-party Collection; Beneficiary Counseling And Assistance Coordinators (BCACs)– Implements policy, assigns responsibilities and

prescribes procedures for Healthcare delivery at MTFs International military reciprocal healthcare agreements Beneficiary Counseling and Assistance Coordinator

responsibilities

– Authorizes Classification Nomenclature and Definitions Relating to Fixed

and Non-fixed MTFs (DoD 6015.1-M) Military Treatment Facility Uniform Business Office (UBO)

(DoD 6010.15-M)


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Instructions (DoDIs) DoDI 6010.23 – DoD/DVA Health Care Resource

Sharing Program– Implements policy, assigns responsibilities, and prescribes

procedures to develop/operate DoD/VA Health Care Resource Sharing Agreements when it is determined that resource sharing will improve access to quality health care or increase cost-effectiveness of the health care provided by MHS and DVA to beneficiaries of both Departments

DoDI 6025.18 – Privacy of Individually Identifiable Health Information in DoD Health Care Programs

– Was originally a Directive (6025.18)– Establishes policy and assigns responsibilities to implement

standards for privacy of individually identifiable health information


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DoDI 6040.40 – Military Health System Data Quality Management Control Procedures

– Policy to implement the MHS Data Quality Management Control (DQMC) program

DoDI 6040.42 – Medical Encounter and Coding at Military Treatment Facilities

– Implements policy, assigns responsibilities, and prescribes procedures for the documentation and coding of outpatient medical encounters in MTFs


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DoDI 5505.12 – Anti-Fraud Program at Military Treatment Facilities (MTFs)

– Implements policy, assigns responsibilities, and prescribes procedures to prevent, detect, report, and evaluate suspected fraud by contracted civilian healthcare providers at all DoD MTFs

2010 UBO/UBU ConferenceTurning Knowledge Into Action Instructions (DoDIs)

DoDI 1000.24 – Confiscation of Fraudulent Identification (ID) Cards at Military Treatment Facilities– MTFs must have an ID card fraud policy program – MTFs have a duty to identify and eliminate eligibility

fraud– Checking eligibility in DEERS – MTF must seek recovery of costs for any medical

care furnished to anyone found to be ineligible

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DoDI 1000.24 – Common situations that affect eligibility:– Separation from the Service– Eligible children reach the age of 21 (except for

certain situations)– Divorce from a sponsor (unless the spouse meets

certain eligibility requirements)– Sponsors must report, within 30 days, any change in

their own status, or that of a family member, that affects eligibility for medical care.

Otherwise, they run the risk of being financially responsible for any medical care provided

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DoDI 1000.24– MTFs should ensure that a responsible individual

reviews the daily CHCS report listing individuals who received care and are not in DEERS

– MTFs are not the final decision-makers on beneficiary eligibility for care

Only Service Personnel offices can make final determinations of beneficiary eligibility

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DoD Directives (DoDDs)

Broad policy documents Establish or describe policy, programs, and

organizations Define missions Provide authority Assign responsibilities


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DoDD 5400.11 – DoD Privacy Program

DoDD 6010.04 – Healthcare for Uniformed Services Members and Beneficiaries

The Uniformed Services shall operate medical and dental treatment facilities in accordance with applicable law, regulation, and policy

The CHAMPUS/TRICARE health care entitlement shall be provided consistent with current law

Health care beneficiaries shall be provided access to military treatment facilities


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DoDD 6025.13 – Medical Quality Assurance (MQA) in the Military Health System (MHS)

– Establishes DoD policy on issues related to MQA programs and activities

DoDD 6040.41 – Medical Records Retention and Coding at Military Treatment Facilities

– Establishes policy and assigns responsibilities for administering medical records retention and encounter coding

– Provides medical records retention and coding reporting– Provides guidance for medical records retention and

encounter coding at MTFs


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DoD Publications

Implement or supplement a Directive or Instruction– Provide uniform procedures for management or

operational systems and disseminating administrative information

Manual– Guidance document that has procedures with examples

for performing specific tasks


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DoD Publications

DoD 6010.15-M– UBO Manual

DoD 6010.13-M– MEPRS Manual

DoD 7000.14-R– DoD Financial Management Regulation


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DoD Publications

DoD 5400.11-R– DoD Privacy Program

Prescribes uniform procedures for implementation of the DoD Privacy Program

DoD 6025.18-R– DoD Health Information Privacy Regulation

Outlines uses and disclosures of protected health information

DoD 8580.02-R – DoD Health Information Security Regulation

Implements HIPAA


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DoD Publications

DoD 6015.1-M – Glossary of Healthcare Terminology

Uniform glossary of healthcare terminology for use throughout the Department of Defense

DoD 6025.13-R– Military Health System Clinical Quality Assurance

Program Regulation Identifies the various components comprising DoD’s

efforts to ensure that beneficiaries receive quality care


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Summary

Recognize the differences between statutes (laws), regulations, policies, directives, instructions, and manuals

Identify those policies that directly affect how you do your job


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Quiz

True or False:– Congress passes HA Policies– A policy is more important than a statute– Cosmetic surgery is a free covered benefit for all

TRICARE beneficiaries

briefing: basic policies

Documents