VA: How UCR Charges are Determined

November 20th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Billing   Insurance  
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How does the VA determine charges billed to third party payers for veterans with private health insurance?

According to the VA, "38 C.F.R 17.101 stipulates the basic methodology by which VA bills third party insurance carriers. In order to generate a charge for medical services, VA establishes reasonable charges for five categories of charges:

  1. Inpatient facility
  2. Skilled nursing facility (SNF)/sub-acute inpatient facility
  3. Outpatient facility
  4. Physicians
  5. Nonphysician providers

Reasonable charges are developed nationally and then adjusted locally by each VA medical center based on their Geographical Area Adjustment Factor (GAAF). Billing for inpatient facilities and skilled nursing facilities are on a per diem basis. For inpatient facility charges, the per diem charges vary by the treated condition as classified by Medicare Severity Diagnosis Related Groups (MS-DRG) codes. Billing for outpatient facility and provider charges vary by procedure performed as classified by current procedural terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) Level II codes. Data for calculating actual charge amounts are published in a notice within the Federal Register or can be viewed on the VHA OCC website."

VA.gov

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