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Notice

TRICARE; Hospital Outpatient Radiology Discretionary Appeal Adjustments

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Information about this document as published in the Federal Register.

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AGENCY:

Office of the Secretary, Department of Defense (DoD).

ACTION:

Notice.

SUMMARY:

This notice is to advise hospitals of an opportunity for net adjusted payments for radiology services for which TRICARE payments were not comparable to the pre-Outpatient Prospective Payment System (OPPS) Medicare fair rates for the period Start Printed Page 49459August 1, 2003, to May 1, 2009 (or other appropriate end date for OPPS-exempt hospitals.)

DATES:

The agency must receive a hospital's request on or before June 23, 2011, or October 11, 2011 for hospitals that did not receive notification by letter.

ADDRESSES:

TRICARE Management Activity (TMA), Medical Benefits and Reimbursement Branch, 16401 East Centretech Parkway, Aurora, CO 80011-9066.

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FOR FURTHER INFORMATION CONTACT:

Martha M. Maxey, Medical Benefits and Reimbursement Branch, TMA, telephone (303) 676-3627.

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SUPPLEMENTARY INFORMATION:

In reviewing payments for hospital outpatient services, DoD has determined that, for radiology services specified in the regulation as being reimbursed under the allowable charge methodology, the technical component of the allowable charge did not approximate the Medicare fair payment for such hospital services as well as it could have. That is, in looking at the Medicare reimbursement methodologies in existence prior to adoption of Medicare's OPPS in 2000, (methodologies resulting in fair payment for Federal health care, which TRICARE allowable charges for hospitals outpatient services were intended to emulate), some radiology services were underpaid in comparison.

The National Defense Authorization Act for Fiscal Year 2002 required that TRICARE use Medicare reimbursement rates for hospitals to the extent practicable. While payments were made in accordance with 32 Code of Federal Regulation, 199.14, there is a basis for TRICARE to make discretionary net adjusted payments for radiology services for which TRICARE payments were not comparable to the pre-OPPS Medicare fair rates for the period in question.

On April 25, 2011, TMA mailed letters to thousands of hospitals notifying them of this opportunity. The hospitals (or their recovery agents) have until June 23, 2011, 60 days from the date of notification, to file an appeal for pay adjustments that will be adjudicated by TMA. Hospitals that did not receive notification by mail have 60 days from August 10, 2011.

Critical Access Hospitals (CAHs) which are not subject to TRICARE's OPPS shall submit a request for the period August 1, 2003, to November 30, 2009. As of December 1, 2010, the payments to CAHs are based on reasonable cost and thus potential adjustments would not apply. Other hospitals not subject to OPPS (such as Cancer and Children's hospitals) shall submit a request for the period August 1, 2003, to December 31, 2010.

The payment adjustment process along with the notification letter to hospitals can be viewed at TMA's Web site at: http://www.tricare.mil/​RadiologyDiscretionaryAppealAdjustments.

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Dated: July 8, 2011.

Patricia Toppings,

OSD Federal Register Liaison Officer, Department of Defense.

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[FR Doc. 2011-20235 Filed 8-9-11; 8:45 am]

BILLING CODE 5001-06-P