How Much Does this Procedure Cost? North Carolina Proposes Temporary Rules on Cost Reporting Requirements for Hospitals and Ambulatory Surgery Centers

The recently adopted North Carolina Health Care Cost Reduction and Transparency Act aims to improve transparency in healthcare costs by providing information to the public.  By January 1, 2015, the Medical Care Commission (MCC) is required to adopt rules establishing reporting requirements for hospitals and ambulatory surgical facilities.  This information will then be available to the public on the North Carolina Department of Health and Human Services’ (Department) website.  The MCC has submitted proposed temporary rules and is accepting public comments through October 17, 2014.  The public hearing on these rules will be on October 15, 2014.  The reporting requirements of these proposed rules are summarized below.

Reporting Requirements for Hospitals
The Department will determine the 100 most frequently reported diagnosis related groups (“DRGs”), the 20 most common outpatient imaging procedures, and the 20 most common outpatient surgical procedures performed in hospitals statewide.  Hospitals will be required to provide the following:

  1. The average gross charge for each DRG or procedure if paid in full without any portion paid by a public or private third party;
  2. The average negotiated settlement for patients not covered by a public or private third party;
  3. The amount of Medicaid reimbursement for each DRG or procedure;
  4. The amount of Medicare reimbursement for each DRG or procedure; and
  5. For the top five largest health insurers (meaning Department of Justice (“DOJ”)-licensed third parties and the State Health Plan):
  • Identify the top five largest health insurers by dollar volume of payments;
  • List the lowest payment from each insurer for each DRG or procedure;
  • List the average of each of the five insurer payment amounts;
  • List the highest payment from each insurer for each DRG or procedure; and
  • Redact names of top five health insurers prior to submission.

Reporting Requirements for Ambulatory Surgical Facilities
The Department will determine the 20 most common outpatient imaging procedures and the 20 most common outpatient surgical procedures performed in ambulatory surgical facilities statewide.  Ambulatory surgical facilities will be required to provide the following:

  1.  The average gross charge for each DRG or procedure if paid in full without any portion paid by a public or private third party;
  2. The average negotiated settlement for patients not covered by a public or private third party;
  3. The amount of Medicaid reimbursement for each DRG or procedure;
  4. The amount of Medicare reimbursement for each DRG or procedure; and
  5. For the top five largest health insurers (meaning DOI-licensed third parties and the State Health Plan):
  • Identify the top five largest health insurers by dollar volume of payments;
  • List the lowest payment from each insurer for each DRG or procedure;
  • List the average of each of the five insurer payment amounts;
  • List the highest payment from each insurer for each DRG or procedure; and
  • Redact names of top five health insurers prior to submission.

Each quarter, hospitals and ambulatory surgical facilities must report on the quarter ending three months previous to the date of reporting.

 

Comments to these proposed temporary rules can be submitted by:

Email: DHSR.RulesCoordinator@dhhs.nc.gov;
Fax: 919-733- 7021;
Mail: Megan Lamphere, Division of Health Service Regulation, 2701 Mail Service Center, Raleigh, NC 27699-2701.

The Public Hearing on October 15, 2014 at 10:00 a.m. will be held at 801 Biggs Drive, Raleigh, NC 27603, Brown Building, Room 104.

Varsha Gadani

Varsha Gadani

Varsha Gadani focuses her practice on the health care industry. Her clients include hospitals, physicians, behavioral health care providers, long-term care facilities, and other providers. Prior to joining Parker Poe, Ms. Gadani served as Assistant Counsel at the North Carolina Medical Society (NCMS). In this role, she performed a variety of legal functions for the NCMS. She monitored and analyzed emerging state and federal health law issues and advised physicians on health policy matters.

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