Understanding Facility Fees in Hospital Outpatient Services

Facility Fee Changes Calendar Year CY 2022 Reporting September 14, 2023 Presented by: Bozena Piascik

Legislative Facility Fee Mandate (old) C.G.S. 19a-508c(m)(1) requires hospitals/hospital health systems to report certain information on facility fees charged or billed for outpatient services provided at hospital-based off-campus locations to OHS, annually. 2

Legislative Facility Fee Mandate C.G.S. 19a-508c(m)(1) requires hospitals/hospital health systems to report certain information on facility fees charged or billed for outpatient services provided at hospital-based on and off-campus locations to OHS, annually. Public Act No. 23-171 9 requires each hospital and hospital health system to report activity for calendar year 2022, not later than October 1, 2023, and thereafter, not later than July 1st each year. 3

Public Act No. 23-171 9 additional changes Requires hospitals/hospital health systems to provide data on which facility fee was charged or billed and indicate whether each facility is located on-campus or off-campus. Extends facility fee prohibition to certain services on a hospital campus From July 1, 2024, unless a contract is already in place, any hospital or hospital health system may not collect a facility fee on certain outpatient health care services (evaluation & management and assessment & management CPT codes) that are provided on a hospital campus. Exclusions include services provided at an emergency department (ED) or freestanding ED; observation stays occurring on a hospital campus; wound care, orthopedics, anticoagulation, obstetrics, and solid organ transplant services. 4

What is a Facility Fee? A facility fee is any fee charged or billed by a hospital or hospital health system for outpatient hospital services provided in a hospital-based facility that is Intended to compensate the hospital or hospital health system for the operational expenses of the hospital or hospital health system; and Separate and distinct from a professional fee. (A hospital-based facility means a facility that is owned or operated, in whole or in part, by a hospital or hospital health system where hospital or professional medical services are provided) 5

. Facility Fee Reporting Hospitals and hospital health systems must file facility fee data to OHS for outpatient facilities services that bill a professional fee and a facility fee. To be included in the filing: Completed and signed Facility Fee Billing Affidavit; Facility Fee Notification Affidavit (if applicable); Written notice, with tag lines by October 2, 2023; Sample of a billing statement by October 15, 2023; Completed Excel spreadsheets Table 1 and Table 2; and All updated forms are available on OHS website. Hospitals and hospital health systems that do not charge both a professional and facility fee for any outpatient services still need to submit a billing affidavit with OHS. 6

Table 1 changes Data is based on top 10 procedures/services generating the greatest amount of facility fees paid. Updated reporting template. Facility fees paid- the total amount of facility fees paid which includes the insurer paid amount and member/patient out of pocket amount. New data (Column C)- indicate whether each facility is located on-campus or off-campus. Language Revised (Column D)- to describe the top ten procedures/services by CPT/HCPCS that include professional fees that generated the greatest amount of facility fee paid. Language Revised (Column E)- volume (unit) for which facility fees were paid. Language Revised (Column F)- facility fees paid. New data (Column G)- total facility fee gross charges by hospital or hospital health system. Data is based on top 10 procedures/services generating the greatest facility fee volume (units). New data (Column H)- indicate whether each facility is located on-campus or off-campus. Language Revised (Column I)- facility fees were paid based on volume (units). Language Revised (Column K)- list total facility fees paid. New data (Column L)- report total facility fee gross charges. 7

Table 1 Reporting Form Activity generated based on volume in units (Col I-Col L) Col I Indicate the # of billed units for each entity listed in Column A and Activity generated based on payments (Col D-Col G) Col A Col B Col C Col D Col E Col F Col G Col H Col J Col K Col L Indicate the # of billed units for each entity listed in Column A and the ten procedures/services by CPT code listed in Column D for which facility fees were paid For each entity listed in Column A, describe the top ten procedures/services by CPT code that generated the greatest amount of facility fees paid For each For each For each entity listed in Column A, describe the top ten procedures/services by CPT code for which facility fees were paid based on # of billed units For each For each procedure/service description listed in Column D list total facility fees paid to the Hospital or Health System procedure/service description listed in Column D list total facility fee gross charges by Hospital or Health System. procedure/service description listed in Column I list total facility fee gross charges by Hospital or Health System. procedure/service description listed in Column I list total facility fees paid to the Hospital or Health System Identify the Reporting Health System and each of its affiliated Hospitals Off campus or On campus Off campus or On campus the ten Rank procedures/services for which facility fees were paid based on # of billed units in Column I Example: XYZ Health System CPT Code and Description Procedure/Service AAA CPT Code and Description Procedure/Service BBB CPT Code and Description Procedure/Service CCC ETC ETC ETC ETC ETC ETC ETC CPT Code and Description Procedure/Service AAA CPT Code and Description Procedure/Service BBB CPT Code and Description Procedure/Service CCC ETC ETC ETC ETC ETC ETC ETC Off campus 2,000 (Example) $50,000 (Example) $150,000 (Example) Off campus 5,000 (Example) $20,000 (Example) $55,000 (Example) 1 Off campus 1,500 (Example) $30,000 (Example) $80,000 (Example) Off campus 4,000 (Example) $10,000 (Example) $35,000 (Example) 2 Off campus 1,000 (Example) $25,000 (Example) $50,000 (Example) Off campus 3,000 (Example) $5,000 (Example) $20,000 (Example) 3 4 5 6 7 8 9 10 ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC Example ABC Hospital within this System CPT Code and Description Procedure/Service AAA CPT Code and Description Procedure/Service BBB CPT Code and Description Procedure/Service CCC ETC ETC ETC ETC ETC ETC ETC CPT Code and Description Procedure/Service AAA CPT Code and Description Procedure/Service BBB CPT Code and Description Procedure/Service CCC ETC ETC ETC ETC ETC ETC ETC On campus 800 (Example) $20,000 (Example) $40,000 (Example) On campus 1000 (Example) $15,000 (Example) $35,000 (Example) 1 On campus 500 (Example) $10,000 (Example) $30,000 (Example) On campus 700 (Example) $12,000 (Example) $32,000 (Example) 2 On campus 300 (Example) $5,000 (Example) $20,000 (Example) On campus 500 (Example) $10,000 (Example) $28,000 (Example) 3 4 5 6 7 8 9 10 ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC ETC NOTE 1: For any information on this table, that is estimated by the Hospital/System using a formula or methodology, provide a full explanation of the estimating methodology and assumptions and explain why actual figures are unavailable. NOTE 2 : Sec. 19a-508c Campus means: (A) The physical area immediately adjacent to a hospital's main buildings and other areas and structures that are not strictly contiguous to the main buildings but are located within two hundred fifty yards of the main buildings, or (B) any other area that has been determined on an individual case basis by the Centers for Medicare and Medicaid Services to be part of a hospital's campus. NOTE 3: Gross charges - the amount charged by the hospital or health system for facility fees. 8 NOTE 4: Facility fees paid - The total amount of facility fees paid which should include the insurer paid amount and member/patient out of pocket amount. NOTE 5: Report CPT/ HCPCS codes that include professional fees.

Table 2 Changes Data is based on facility fees generated by payer type/source. New data (Column C)- report whether each facility is located on- campus or off-campus of a hospital. New data (Column H)- report the total amount of all other patient visits for which facility fees were paid. In addition, provide a general description of these visits at the bottom of the worksheet. New data (Column L)- report the total amount of all other facility fees paid. New data (Column T)- report the total amount of facility fee gross charges by the hospital or hospital health system. 9

Table 2 Reporting Form Col A Col B Col C Col D Col E Col F Col G Col H Col I Col J Col K Col L Col M Col N Col O Col P Col Q Col R Col S Col T # of patient visits for which facility fees were paid under private insurance policies # of patient visitsfor which a facility feeb was charged/ billed List each facility owned or operated by the Reporting System or Hospital that provides Outpatient Services for which a facility fee is charged/billed (list name)a # of all other patient visits for which facility fees were paid (describe belowe) List the minimumd facility fee paid under private insurance policies List the maximumd facility fee paid under private insurance policies Total amountc of facility fees paid under private insurance policies # of patient visits for which facility fees were paid by Medicaref # of patient visits for which facility fees were paid by Medicaid Total List the maximumd facility fee paid by Medicaref Total Total List the minimumd facility fee paid by Medicare List the minimumd facility fee paid by Medicaid List the maximumd facility fee paid by Medicaid Total amount of facility fees paid to the Hospital or Health System Total facility fee gross charges by the Hospital or Health System amountcof facility fees paid by Medicaref amountc of facility fees paid by Medicaid amountc of all other facility fees paid Address for facility listed in Col A Is the location in Col B On campus or Off campus Facility Name Facility Name Facility Name Address Address Address On or Off campus On or Off campus On or Off campus Number 1 1 Number 1 1 Number 1 1 Number 1 1 Number 1 1 $$ $10 $10 $$ $10 $10 $$ $10 $10 $$ $10 $10 Min Fee$$ Min Fee$$ Min Fee$$ Max Fee$$ Max Fee$$ Max Fee$$ Min Fee$$ Min Fee$$ Min Fee$$ Max Fee$$ Max Fee$$ Max Fee$$ Min Fee$$ Min Fee$$ Min Fee$$ Max Fee$$ Max Fee$$ Max Fee$$ $$ $40 $40 $$ $100 $100 Total 2 2 2 2 2 $20 $20 $20 $20 $80 $200 NOTE: For any information on this table, that is estimated by the Hospital/System using a formula or methodology, provide a full explanation of the estimating metholodology and assumptions and explain why actual figures are unavailable. aInformation in Columns B - T are for each Facility. Facility means a hospital-based facility located on or outside a hospital campus (Campus is defined in Section 19a-508c(a)(2) as: (A) The physical area immediately adjacent to a hospital's main buildings and other areas and structures that are not strictly contiguous to the main buildings but are located within two hundred fifty yards of the main buildings, or (B) any other area that has been determined on an individual case basis by the Centers for Medicare and Medicaid Services to be part of a hospital's campus;). b - Facility fees reported in columns D-S should be limited to those that are permissible under State or Federal laws. c The total amount of facility fees paid by this payer source which includes the insurer paid amount and member/patient out of pocket amount. d The range of facility fees paid by this payer source which includes the insurer paid amount and member/patient out of pocket amount. eBesides Medicare, Medicaid and private insurance policies, report the total amount of all other patient visits for which facility fees were paid. In addition, provide a general description of these visits at the bottom of the worksheet. fReport Medicare Advantage visits and payments in the Medicare column. 10

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For more information on facility fees visit https://portal.ct.gov/OHS/Health-Systems- Planning/Notifications/Facility-Fees To know more about OHS visit https://portal.ct.gov/OHS 12