PENNSYLVANIA - BILLING ISSUES

January 1, 2008

Pennsylvania state laws and regulations that affect your medical practice

1. Is balance billing permitted in Pennsylvania?

No. Balance billing by health care practitioners is prohibited. This includes any primary health center, corporation, facility, institution or other entity that employs a health care practitioner.

35 P.S. § 449.34

No. Providers may not bill an insured automobile accident victim directly but must bill the insurer for a determination of the amount payable. The provider shall not bill or otherwise attempt to collect from the insured the difference between the provider's full charge and the amount paid by the insurer.

75 Pa. C.S.A. § 1797

3. What is the Health Care Cost Containment Council?

To promote health care cost containment, the Commonwealth of Pennsylvania established an independent council to be known as the Health Care Cost Containment Council. The need for such a council became apparent due to the major crisis in Pennsylvania caused by the continuing escalation of costs for health care services. Because of the continuing escalation of costs, an increasingly large number of Pennsylvania residents have severely limited access to appropriate and timely health care. Increasing costs are also undermining the quality of health care services currently being provided. Further, the continuing escalation is negatively affecting the economy of Pennsylvania, is restricting new economic growth and is impeding the creation of new job opportunities.

The continuing escalation of health care costs is attributable to a number of interrelated causes, including:

( a ) Inefficiency in the present configuration of health care service systems and in their operation.

( b ) The present system of health care cost payments by third parties.

( c ) The increasing burden of indigent care which encourages cost shifting.

( d ) The absence of a concentrated and continuous effort in all segments of the health care industry to contain health care costs.

The Health Care Cost Containment Council was created to facilitate the continuing provision of quality, cost-effective health services by providing current, accurate data and information to the purchasers and consumers of health care on both cost and quality of health care services and to public officials for the purpose of determining health-related programs and policies and to assure access to health care services.

35 P.S. § 449.2

4. How does the Health Care Cost Containment Council achieve its goals?

The council is authorized by the Legislature to collect, and data sources are required to submit, upon request of the council, all data required by the Health Care Cost Containment Act, according to uniform submission formats, coding systems and other technical specifications. The council adopted a Pennsylvania Uniform Claims and Billing Form format, which must be used and maintained by all data sources for all services covered by the Act.

For each covered service performed in Pennsylvania, the council shall be required to collect the following data elements:

Field...............Data Element......................................Definition

1.......Uniform Patient Identifier......................................Patient's Social Security Number.

2.......Patient Date of Birth.............................................Patient's Date of Birth.

3.......Patient Sex............................................................The sex of the patient as recorded at the date of admission, outpatient service, or start of care.

4.......Patient Zip Code...................................................Zip code of patient taken from the patient name and address field.

5.......Date of Admission.................................................The date that the patient was admitted to the provider for inpatient care, outpatient services or start of care.

6.......Date of Discharge..................................................The ending service date of patient care. The date that the patient was discharged from the provider's care.

7a.......Principal Diagnosis.................................................The code that identifies the principal diagnosis (i.e., the condition established after study to be chiefly responsible for causing this hospitalization) that exists at the time of admission or develops subsequently that has an effect on the length of stay.

7b, c, d, e.......Secondary Diagnosis..................................The diagnosis code corresponding to additional conditions that co-exist at the time of admission, or develop subsequently, and which have an effect on the treatment received or the length of stay.

8a, b.......Principal Procedure Code and Date....................The code that identifies the principal procedure performed during the period between admission and discharge and the date on which the principal procedure described was performed.

9a1 through 9c2.......Secondary Procedure....................... The code identifying the procedures other than the principal procedure, performed during the patient's stay and the dates on which the procedures (identified by the codes) were performed.

10.......Uniform Identifier Health Care Facility......................Number identifying the provider facility as developed and used by Medicaid.

11.......Attending Physician Identifier....................................The PA state license number of the physician who would normally be expected to certify and recertify the medical necessity of the services rendered and/or who has primary responsibility for the patient's medical care and treatment.

12.......Operating Physician Identifier...................................The PA state license number of the physician other than the attending physician who performed the principal procedure.

13a1 through 13w1.......Revenue Description.......................A narrative description of the related revenue categories included for a patient.

13a2 through 13w2.......Revenue Code................................A code which identifies a specific accommodation, ancillary service or billing calculation.

13a3 through 13w3.......Units of Service...............................A quantitative measure of services rendered by revenue category to or for the patient to include items such as number of accommodation days, pints of blood, or renal dialysis treatments, etc.

13a4 through 13w4.......Total Charges................................. Total charges pertaining to the related revenue code.

13a5 through 13w5.......Noncovered Charges.......................Those charges that are not covered by a payor for this patient.

14a.......Actual Payments to the Health Care.........................Payments for services performed by the provider from the payor segregated according to Revenue Code.

14b.......Payor Identification..................................................Name and Pennsylvania Insurance Department number identifying each payor organization from which the provider might expect some payment for the bill.

14c.......Deductible Amount..................................................The amount assumed by the hospital to be applied to the patient's deductible amount involving the indicated payor.

14d.......Co-Insurance Amount.............................................The amount assumed by the hospital to be applied toward the patient's co-insurance amount involving the indicated payor.

14e.......Estimated Responsibility..........................................The amount estimated by the hospital to be paid by the indicated payor.

14f.......Prior Payments – Payor and Patient...........................The amount the hospital has received toward payment of this bill prior to the billing date by the indicated payor.

14g.......Estimated Amount....................................................The amount estimated by the hospital to be due from the indicated payor (estimated responsibility less prior payments).

15a.......Physician Identification.............................................License number of the physician who charged the patient for a service related to an episode of illness for the period indicated in Fields 5 and 6.

15b.......Type of Physician/Professional Service.....................The type of service performed for which payment is expected.

15a3.......Physician/Professional Services Charge...................Amount charged for services rendered to the patient for the procedure indicated in HCFA 1500, item 24d

16.......Physician/Professional Services Payment.....................Payments received for services performed for the procedures indicated in Field 8a.

17.......Uniform Identifier Of Primary Payor.........................Pennsylvania Department of Insurance number. If the number is not available, the Health Care Cost Containment Council will assign a number based on the name in Field 14b.

18.......Zip Code of Facility...................................................Five character zip code with a four character extension. If the four character extension is unknown, fill with blanks.

19.......Payor Group Number...............................................The identification number, control number, or code assigned by the carrier or plan administrator to identify the group under which the individual is covered.

20.......Patient Discharge Status............................................The status of the patient at discharge.

21c.......Unusual Occurrence.................................................Infections acquired while in the hospital. Nosocomial infections are defined as those infections that are clinically manifested after 72 hours in the hospital, unless: 1. They are evident within 72 hours after admission and are related to a previous hospitalization; 2. They are related to a hospital procedure performed within the first 72 hours.

21d.......Unusual Occurrence.................................................Patient readmission to the hospital within 30 days.

22.......Type of Bill..............................................................A code indicating the specific type of bill (inpatient, outpatient, adjustments, voids, etc.).

23.......Patient Control.........................................................Patient's unique alphanumeric number assigned by the provider to facilitate retrieval of individual case records and posting of the payment.

24.......Diagnosis Related....................................................The condition established after study as being chiefly responsible for the admission of a patient to the hospital for care that exists at the time of admission or develops subsequently that has an effect on the length of stay.

25.......Procedure Coding Method Used.............................An indicator that identifies the coding method used for procedure coding on this bill.

26.......Type of Admission..................................................A code indicating the priority of this admission.

27.......Source of Admission...............................................A code indicating the source of this admission.

28.......Patient's Relationship to Insured...............................A code indicating the relationship of the patient to the identified insured.

29.......Certificate/Social Security Number/ Health Insurance Claim/Identification Number.......................Insured's unique identification number assigned by the payor organization.

30.......Principal and Other Diagnoses..................................Narrative description of the principal diagnosis (i.e., the condition established after study to be chiefly responsible for causing the hospitalization or use of hospital services) and other diagnoses.

31.......Principal and Other.................................................A narrative description of the principal procedure (i.e. the procedure that was performed for definitive treatment rather than the one performed for diagnostic or exploratory purposes of the procedure most related to the principal diagnosis) and other procedures. The principal procedure is to be shown first.

32.......Employer Name.....................................................The name of the employer that might or does provide health care coverage for the individual identified in Field 33.

33.......Employment..........................................................A code that indicates whether the employment information given in the related areas applies to an insured, the patient or the patient's spouse.

34.......Employment Status...............................................Code A code used to define the employment status of the individual identified in Field 33.

35.......Patient Race........................................................This code indicates the patient's race/ethnic background.

36.......Reserve Field.......................................................To be reserved for future use by the Council.

35 P.S § 449.6; 28 PA ADC § 911.4

5. What does the Health Care Cost Containment Council do with the collected data?

( a ) Public Reports. The council shall prepare and issue reports to the General Assembly and to the general public, according to the following provisions:

( 1 ) The council shall, for every provider of both inpatient and outpatient services within Pennsylvania and within appropriate regions and subregions, prepare and issue reports on provider quality and service effectiveness on diseases or procedures that, when ranked by volume, cost, payment and high variation in outcome, represent the best opportunity to improve overall provider quality, improve patient safety and provide opportunities for cost reduction. These reports shall provide comparative information on the following:

( i ) Differences in mortality rates; differences in length of stay; differences in complication rates; difference in readmission rates; differences in infection rates; and other comparative outcome measures the council may develop that will allow purchasers, providers and consumers to make purchasing and quality improvement decisions based upon quality patient care and to restrain costs.

( ii ) The incidence rate of selected medical or surgical procedures, the quality and service effectiveness and the payments received for those providers, identified by the name and type of specialty, for which these elements vary significantly from the norms of all providers.

( 2 ) In preparing its reports under paragraph ( 1 ), the council shall ensure that factors which have the effect of either reducing provider revenue or increasing provider costs and other factors beyond a provider's control which reduce provider competitiveness in the marketplace are explained in the reports. The council shall also ensure that any clarifications and dissents submitted by individual providers are noted in any reports that include release of data on that individual provider.

( b ) Raw data reports and computer access to council data. The council shall provide special reports derived from raw data and a means for computer-to-computer access to its raw data to any purchaser. The council shall provide such reports and computer-to-computer access, at its discretion, to other parties. The council shall provide these special reports and computer-to-computer access in as timely a fashion as the council's responsibilities to publish the public reports required in this section will allow. Any such provision of special reports or computer-to-computer access by the council shall be made subject to restrictions on access to raw data and only after payment for costs of preparation or duplication.

35 P.S. § 449.7

Copyright Kern Augustine Conroy and Schoppmann, P.C. Used with permission.