Or. Admin. Code § 436-009-0020 - Hospitals
(1)
Inpatient.
(a) For the purposes
of this rule, hospital inpatient services are those services that are billed
with codes "0111" through "0118" in form locator #4 on the UB-04 billing
form.
(b) Hospital inpatient bills
must include:
(A) For dates of service prior
to Oct. 1, 2015, ICD-9-CM codes, and for dates of service on and after Oct. 1,
2015, ICD-10-CM codes;
(B) When
applicable, procedural codes;
(C)
The hospital's NPI; and
(D) The
Medicare Severity Diagnosis Related Group (MS-DRG) code, except for:
(i) Bills from critical access hospitals,
(See Bulletin 290); or
(ii) Bills
containing revenue code 002x.
(c) Unless otherwise provided by contract,
the insurer must pay the audited bill for hospital inpatient services by
multiplying the amount charged by the hospital's adjusted cost-to-charge ratio
(See Bulletin 290). The insurer must pay in-state hospitals not listed in
Bulletin 290 at 80 percent of billed charges for inpatient services.
(2)
Outpatient.
(a) For the purposes of this rule, hospital
outpatient services are those services that are billed with codes "0131"
through "0138" in form locator #4 on the UB-04 billing form.
(b) Hospital outpatient bills must, when
applicable, include the following:
(A) Revenue
codes;
(B) For dates of service
prior to Oct. 1, 2015, ICD-9-CM codes, and for dates of service on and after
Oct. 1, 2015, ICD-10-CM codes,
(C)
CPT® codes and HCPCS codes; and
(D) The hospital's NPI.
(c) Unless otherwise provided by contract,
the insurer must pay for hospital outpatient services as follows: [See attached
table.]
(3)
Specific Circumstances. When a patient is seen initially in an
emergency department and is then admitted to the hospital for inpatient
treatment, the services provided immediately prior to admission are considered
part of the inpatient treatment. Diagnostic testing done prior to inpatient
treatment is considered part of the hospital services subject to the hospital
inpatient fee schedule.
(4)
Out-of-State Hospitals.
(a)
Unless otherwise agreed upon by the hospital and the insurer, insurers must pay
an out-of-state hospital for inpatient services as outlined in subsection
(1)(c) of this rule and for outpatient services as outlined in subsection
(2)(c) of this rule.
(b) The
payment to out-of-state hospitals may be negotiated between the insurer and the
hospital.
(c) Any agreement for
payment less than the Oregon fee schedule amount must be in writing and signed
by the hospital and insurer representative.
(d) The agreement must include language that
the hospital will not bill the patient any remaining balance and that the
negotiated amount is considered payment in full.
(e) Notwithstanding OAR
436-009-0010(8),
if the insurer and the hospital are unable to reach an agreement within 45 days
of the insurer's receipt of the bill, the insurer must pay an out-of-state
hospital for inpatient services as outlined in subsection (1)(c) of this rule
and for outpatient services as outlined in subsection (2)(c) of this
rule.
(5)
Calculation of Cost-to-Charge Ratio Published in Bulletin 290.
(a) Each hospital's CMS 2552 form and
financial statement is the basis for determining its adjusted cost-to-charge
ratio. If a current form 2552 is not available, then financial statements may
be used to develop estimated data. If the adjusted cost-to-charge ratio is
determined from estimated data, the hospital will receive the lower ratio of
either the hospital's last published cost-to-charge ratio or the hospital's
cost-to-charge ratio based on estimated data.
(b) The basic cost-to-charge ratio is
developed by dividing the total net expenses for allocation shown on Worksheet
A, and as modified in subsection (c), by the total patient revenues from
Worksheet G-2.
(c) The net expenses
for allocation derived from Worksheet A is modified by adding, from Worksheet
A-8, the expenses for:
(A) Provider-based
physician adjustment;
(B) Patient
expenses such as telephone, television, radio service, and other expenses
determined by the director to be patient-related expenses; and
(C) Expenses identified as for physician
recruitment.
(d) The
basic cost-to-charge ratio is further modified to allow a factor for bad debt
and the charity care provided by each hospital. The adjustment for bad debt and
charity care is calculated in two steps. Step one: Add the dollar amount for
net bad debt to the dollar amount for charity care. Divide this sum by the
dollar amount of the total patient revenues, from Worksheet G-2, to compute the
bad debt and charity ratio. Step two: Multiply the bad debt and charity ratio
by the basic cost-to-charge ratio calculated in subsection (5)(b) to obtain the
factor for bad debt and charity care.
(e) The basic cost-to-charge ratio is further
modified to allow an adequate return on assets. The director will determine a
historic real growth rate in the gross fixed assets of Oregon hospitals from
the audited financial statements. This real growth rate and the projected
growth in a national fixed weight price deflator will be added together to form
a growth factor. This growth factor will be multiplied by the total fund
balance, from Worksheet G of each hospital's CMS 2552 to produce a fund balance
amount. The fund balance amount is then divided by the total patient revenues
from Worksheet G-2, to compute the fund balance factor.
(f) The factors resulting from subsections
(5)(d) and (5)(e) of this rule are added to the ratio calculated in subsection
(5)(b) of this rule to obtain the adjusted cost-to-charge ratio. In no event
will the adjusted cost-to-charge ratio exceed 1.00.
(g) The adjusted cost-to-charge ratio for
each hospital will be revised annually, at a time based on their fiscal year,
as described by bulletin. Each hospital must submit a copy of its CMS 2552 and
financial statements each year within 150 days of the end of the hospital's
fiscal year to the Information Technology and Research Section, Department of
Consumer and Business Services. The adjusted cost-to-charge ratio schedule will
be published by bulletin yearly.
(h) For newly formed or established hospitals
for which no CMS 2552 has been filed or for which there is insufficient data,
or for those hospitals that do not file Worksheet G-2 with the submission of
their CMS 2552, the division determines an adjusted cost-to-charge ratio for
the hospital based upon the adjusted cost to charge ratios of a group of
hospitals of similar size or geographic location.
(i) If the financial circumstances of a
hospital unexpectedly or dramatically change, the division may revise the
hospital's adjusted cost-to-charge ratio to allow equitable payment.
(j) If audit of a hospital's CMS 2552 by the
CMS produces significantly different data from that obtained from the initial
filing, the division may revise the hospital's adjusted cost-to-charge ratio to
reflect the data developed subsequent to the initial calculation.
(k) Notwithstanding subsections (1)(c) and
(2)(c) of this rule, the director may exclude rural hospitals from imposition
of the adjusted cost-to-charge ratio based upon a determination of economic
necessity. The rural hospital exclusion will be based on the financial health
of the hospital reflected by its financial flexibility index. All rural
hospitals having a financial flexibility index at or below the median for all
Oregon critical access hospitals qualify for the rural exemption. Rural
hospitals that are designated as critical access hospitals under the Oregon
Medicare Rural Hospital Flexibility Program are automatically exempt from
imposition of the adjusted cost-to-charge ratio.
Notes
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 656.726(4), ORS 656.012, ORS 656.236(5), ORS 656.327(2) & ORS 656.313(4)(d)
Statutes/Other Implemented: ORS 656.248, ORS 656.252 & ORS 656.256
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