§17.56. VA payment for inpatient and outpatient health care professional services at non-departmental facilities and other medical charges associated with non-VA outpatient care.
38 C.F.R. § 17.56
Except for health care professional services provided in the state of Alaska (see paragraph (b) of this section), VA will determine the amounts paid under § 17.52 or § 17.120 for health care professional services, and all other medical services associated with non-VA outpatient care, using the applicable method in this section:
If a specific amount has been negotiated with a specific provider, VA will pay that amount.
If an amount has not been negotiated under paragraph (a)(1) of this section, VA will pay the lowest of the following amounts:
The applicable Medicare fee schedule or prospective payment system amount (“Medicare rate”) for the period in which the service was provided (without any changes based on the subsequent development of information under Medicare authorities), subject to the following:
In the event of a Medicare waiver, the payment amount will be calculated in accordance with such waiver.
In the absence of a Medicare rate or Medicare waiver, payment will be the VA Fee Schedule amount for the period in which the service was provided. The VA Fee Schedule amount is determined by the authorizing VA medical facility, which ranks all billings (if the facility has had at least eight billings) from non-VA facilities under the corresponding procedure code during the previous fiscal year, with billings ranked from the highest to the lowest. The VA Fee Schedule amount is the charge falling at the 75th percentile. If the authorizing facility has not had at least eight such billings, then this paragraph does not apply.
The amount negotiated by a repricing agent if the provider is participating within the repricing agent's network and VA has a contract with that repricing agent. For the purposes of this section, repricing agent means a contractor that seeks to connect VA with discounted rates from non-VA providers as a result of existing contracts that the non-VA provider may have within the commercial health care industry.
The amount that the provider bills the general public for the same service.
For physician and non-physician professional services rendered in Alaska, VA will pay for services in accordance with a fee schedule that uses the Health Insurance Portability and Accountability Act mandated national standard coding sets. VA will pay a specific amount for each service for which there is a corresponding code. Under the VA Alaska Fee Schedule, the amount paid in Alaska for each code will be 90 percent of the average amount VA actually paid in Alaska for the same services in Fiscal Year (FY) 2003. For services that VA provided less than eight times in Alaska in FY 2003, for services represented by codes established after FY 2003, and for unit-based codes prior to FY 2004, VA will take the Centers for Medicare and Medicaid Services' rate for each code and multiply it times the average percentage paid by VA in Alaska for Centers for Medicare and Medicaid Services-like codes. VA will increase the amounts on the VA Alaska Fee Schedule annually in accordance with the published national Medicare Economic Index (MEI). For those years where the annual average is a negative percentage, the fee schedule will remain the same as the previous year. Payment for non-VA health care professional services in Alaska shall be the lesser of the amount billed or the amount calculated under this subpart.
Payments made by VA to a non-VA facility or provider under this section shall be considered payment in full. Accordingly, the facility or provider or agent for the facility or provider may not impose any additional charge for any services for which payment is made by VA.
In a case where a veteran has paid for emergency treatment for which VA may reimburse the veteran under § 17.120, VA will reimburse the amount that the veteran actually paid. Any amounts due to the provider but unpaid by the veteran will be reimbursed to the provider under paragraphs (a) and (b) of this section.
Except for payments for care furnished under 38 U.S.C. 1725 and § 17.1005, under 38 U.S.C. 1728 and §§ 17.120 and 17.128, or under 38 U.S.C. 1787 and § 17.410, the provisions of this section shall not apply to care furnished by VA after June 6, 2019, or care furnished pursuant to an agreement authorized by 38 U.S.C. 1703A.
Notes, amendments, and revision history
Amendments
[75 FR 78915, Dec. 17, 2010, as amended at 78 FR 26251, May 6, 2013; 78 FR 68364, Nov. 14, 2013; 79 FR 16200, Mar. 25, 2014; 84 FR 26306, June 5, 2019]
Authority
Authority: 38 U.S.C. 501, and as noted in specific sections. Section 17.30 also issued under 38 U.S.C. 1701. Section 17.32 also issued under 38 U.S.C. 7331-7334. Section 17.35 is also issued under 38 U.S.C. 1724. Section 17.37 is also issued under 38 U.S.C. 101, 1701, 1705, 1710, 1720J, 1721, 1722. Section 17.38 is also issued under 38 U.S.C. 1701 and 1703. Section 17.43 also issued under 38 U.S.C. 109, 1784, 8111, and 8153. Section 17.44 also issued under E.O. 10122, 15 FR 2173, 3 CFR, 1949-1953 Comp., p. 313, E.O. 10400, 17 FR 8648, 3 CFR, 1949-1953 Comp., p. 900, and E.O. 11733, 38 FR 20431, 3 CFR, 1971-1975 Comp., p. 792. Section 17.46 is also issued under 38 U.S.C. 1710. Section 17.47 is also issued under 38 U.S.C. 1701, 1710, 1721, 1722, 1729, 3104(a)(9), 7333, Pub. L. 99-272; 42 U.S.C. 1396 et seq. Section 17.52 is also issued under 38 U.S.C. 1701, 1703, 1710, 1712, and 3104. Section 17.55 is also issued under 38 U.S.C. 513, 1703, and 1728. Section 17.56 is also issued under 38 U.S.C. 1703 and 1728. Sections 17.61 through 17.74 are also issued under 38 U.S.C. 1730. Section 17.86 also issued under 38 U.S.C. 1785. Section 17.101 is also issued under 38 U.S.C. 101, 1701, 1705, 1710, 1721, 1722, 1729. Section 17.102 also issued under 38 U.S.C. 109, 1711, 1729, 1784, 1784A, 1785, 8111, 8153. Section 17.105 is also issued under 38 U.S.C. 501, 1721, 1722A, 1724, and 1725A. Section 17.108 is also issued under 38 U.S.C. 501, 1703, 1710, 1725A, 1720J, and 1730A. Section 17.110 is also issued under 38 U.S.C. 501, 1703, 1710, 1720D, 1720J, 1722A, and 1730A. Section 17.111 is also issued under 38 U.S.C. 101(28), 501, 1701(7), 1703, 1710, 1710B, 1720B, 1720D, 1722A, and 1730A. Section 17.125 is also issued under 38 U.S.C. 7304. Sections 17.156 and 17.157 are also issued under 38 U.S.C. 3901 and 3902. Section 17.158 is also issued under 38 U.S.C. 3902 and 3903. Section 17.169 is also issued under 38 U.S.C. 1712C. Sections 17.243 through 17.248 are also issued under 38 U.S.C. 7302 note. Sections 17.270, and 17.272 through 17.277 are also issued under 38 U.S.C. 1781. Section 17.271 is also issued under 38 U.S.C. 1720G(a)(7)(A) and 1781. Section 17.278 is also issued under 38 U.S.C. 1781 and 42 U.S.C. 2651. Section 17.279 is also issued under 5 U.S.C. 552 and 552a; 38 U.S.C. 1781, 5701, and 7332. Sections 17.380, 17.390 and 17.412 are also issued under sec. 260, Pub. L. 114-223, 130 Stat. 857, and sec. 236, Public Law 115-141, 132 Stat. 348, and sec. 236, div. J, Pub. L 115-141, 132 Stat. 348. Section 17.395 is also issued under 38 U.S.C. 1788. Section 17.410 is also issued under 38 U.S.C. 1787. Section 17.415 is also issued under 38 U.S.C. 7301, 7304, 7402, and 7403. Section 17.417 also issued under 38 U.S.C. 1701 (note), 1709A, 1712A (note), 1722B, 1730C, 7301, 7306, 7330A, 7331, 7401-7403, 7405, 7406, 7408. Section 17.419 also issued under 38 U.S.C. 1701 (note), 7301, 7306, 7330A, 7401-7403, 7405, 7406, 7408). Section 17.450 is also issued under 38 U.S.C. 1703E. Sections 17.525 through 17.531 are also issued under 38 U.S.C. 7691 through 7697. Sections 17.545 through 17.553 are also issued under 38 U.S.C. 7698, 7699, 7699A, and 7699B. Sections 17.600 through 17.612 are also issued under 38 U.S.C. 7601-7619, 7633, 7634, 7636, and sec. 104(a), div. V, Public Law 117-328. Sections 17.613 through 17.618 are also issued under Pub. L. 115-182, sec. 304. Sections 17.640 and 17.647 are also issued under sec. 4, Pub. L. 114-2, 129 Stat. 30. Sections 17.641 through 17.646 are also issued under 38 U.S.C. 501(a) and sec. 4, Pub. L. 114-2, 129 Stat. 30. Section 17.655 also issued under 38 U.S.C. 501(a), 7304, 7405. Sections 17.1200 through 17.1230 are also issued under 38 U.S.C. 1720J. Section 17.3200 also issued under 38 U.S.C. 1162, 1701, 1707, 1710, 1714, 1717, 3901. Section 17.3210 also issued under 38 U.S.C. 1701, 1710. Section 17.3220 also issued under 38 U.S.C. 1701(6)(F), 1710. Section 17.3230 also issued under 38 U.S.C. 1701(6)(F), 1710, 1714(a). Section 17.3250 also issued under 38 U.S.C. 1701, 1710, 1725, 1728. Section 17.3500 is also issued under Pub. L. 102-139 sec. 101. Sections 17.4000 through 17.4040 also issued under 38 U.S.C. 1703, 1703B, and 1703C. Section 17.4100 et seq. is also issued under 38 U.S.C. 1703A. Section 17.4600 is also issued under 38 U.S.C. 1725A and 1730A.
Amendments
[75 FR 78915, Dec. 17, 2010, as amended at 78 FR 26251, May 6, 2013; 78 FR 68364, Nov. 14, 2013; 79 FR 16200, Mar. 25, 2014; 84 FR 26306, June 5, 2019]