C.R.S. Section 25.5-4-216
Report on impact of hospital facility fees in Colorado

  • definitions
  • steering committee
  • repeal

(1)

As used in this section:

(a)

“Affiliated with” has the meaning set forth in section 6-20-102 (1)(a).

(b)

“Campus” has the same meaning set forth in section 6-20-102 (1)(b).

(c)

“CPT code” has the meaning set forth in section 25.5-1-204.7 (1)(d).

(d)

“Facility fee” has the meaning set forth in section 6-20-102 (1)(d).

(e)

“Health-care provider” has the meaning set forth in section 6-20-102 (1)(f).

(f)

“Health system” has the meaning set forth in section 10-16-1303 (9).

(g)

“Hospital” has the meaning set forth in section 6-20-102 (1)(j).

(h)

“Owned by” has the meaning set forth in section 6-20-102 (1)(m).

(i)

“Payer type” has the meaning set forth in section 6-20-102 (1)(n).

(j)

“Steering committee” means the steering committee created in subsection (2) of this section.

(2)

There is created in the state department a steering committee to research and report on the impact of outpatient facility fees. The steering committee consists of the following seven members appointed by the governor with relevant expertise in health-care billing and payment policy:

(a)

Two members representing health-care consumers, with at least one of the members representing a health-care consumer advocacy organization;

(b)

One member representing a health-care payer or payers;

(c)

One member representing health-care providers not affiliated with or owned by a hospital or health system or who has independent physician billing expertise;

(d)

One member representing a statewide association of hospitals;

(e)

One member representing a rural, critical access, or independent hospital; and

(f)

The executive director of the department of health care policy and financing, or the executive director’s designee.

(3)

Intentionally left blank —Ed.

(a)

The steering committee shall facilitate the development of a report detailing the impact of outpatient facility fees on the Colorado health-care system, including the impact on consumers, employers, health-care providers, and hospitals. In developing various aspects of the report required in this section, the steering committee shall work with independent third parties to conduct related research and analysis necessary to identify and evaluate the impact of outpatient facility fees.

(b)

The steering committee shall prepare a preliminary version of the report on or before August 1, 2024, unless more time is required, and a final report on or before October 1, 2024, that must be submitted to the house of representatives health and insurance committee and the senate health and human services committee, or their successor committees.

(4)

Intentionally left blank —Ed.

(a)

For purposes of developing the report, the steering committee, with administrative support from the state department, may:

(I)

Select third-party contractors to assist in researching and creating the report, with an appropriation made to the state department for such purpose;

(II)

Develop the format, scope, and templates for requests for information;

(III)

Review drafts, provide feedback, and finalize the report;

(IV)

Answer technical questions from third-party contractors; and

(V)

Consult with external stakeholders.

(b)

The steering committee, state department, and any third-party contractors engaged in the development of the report are encouraged to use both primary and secondary sources and research, where possible, and, to the extent feasible, ensure the report is well-informed by the perspectives of diverse stakeholders. The steering committee shall work only with third-party contractors that are already approved as one of the state department’s project-based contracts.

(c)

To the extent practicable, evaluation and analysis performed for the report must attempt to leverage Colorado-specific data sources and publicly available national data and research.

(5)

The report must identify and evaluate:

(a)

Payer reimbursement and payment policies for outpatient facility fees across payer types, including insights, where available, into changes over time, as well as provider billing guidelines and practices for outpatient facility fees across provider types, including insights, where available, into changes made over time;

(b)

Payments for outpatient facility fees, including insights into the associated care across payer types;

(c)

Coverage and cost-sharing provisions for outpatient care services associated with facility fees across payers and payer types;

(d)

Denied facility fee claims by payer type and provider type;

(e)

The impact of facility fees and payer coverage policies on consumers, small and large employers, and the medical assistance program;

(f)

The impact of facility fees and payer coverage policies on the charges for health-care services rendered by independent health-care providers, including a comparison of professional fee charges and facility fee charges; and

(g)

The charges for health-care services rendered by health-care providers affiliated with or owned by a hospital or health system, and including a comparison of professional fee and facility fee charges.

(6)

The report must include an analysis of:

(a)

Data from the Colorado all-payer health claims database as reported under DSG14, including, at a minimum:

(I)

The number of patient visits for which facility fees were charged, including, to the extent possible, a breakdown of which visits were in network and which were out of network;

(II)

To the extent possible, the number of patient visits for which the facility fees were charged out of network and the professional fees were charged in network for the same outpatient service;

(III)

The total allowed facility fee amounts billed and denied;

(IV)

The top ten most frequent CPT codes, revenue codes, or combination thereof, at the steering committee’s discretion, for which facility fees were charged;

(V)

The top ten CPT codes, revenue codes, or combination thereof, at the steering committee’s discretion, with the highest total allowed amounts from facility fees;

(VI)

The top ten CPT codes, revenue codes, or combination thereof, at the steering committee’s discretion, for which facility fees are charged with the highest member cost sharing; and

(VII)

The total number of facility fee claim denials, by site of service;

(b)

Data from hospitals and health systems, which data shall be provided to the steering committee, including:

(I)

The number of patient visits for which facility fees were charged;

(II)

The total revenue collected in facility fees;

(III)

A description of the most frequent health-care services for which facility fees were charged and net revenue received for each such service;

(IV)

A description of health-care services that generated the greatest amount of gross facility fee revenue and net revenue received for each such service; and

(V)

Data from off-campus health-care providers that are affiliated with or owned by a hospital or health system, including:

(A)

Historic and current business names and addresses;

(B)

Historic and current tax identification numbers and national provider identifiers;

(C)

Health-care provider acquisition or affiliation date;

(D)

Facility fee billing policies, including whether any changes were made to such policies before or after the acquisition or affiliation date; and

(E)

The top ten CPT codes, revenue codes, or combination thereof, at the state department’s discretion, for which a facility fee is billed and the professional fee amount for the same service;

(c)

Data, if available, from the state department, the division of insurance, and commercial payers, including:

(I)

The payment policy each payer uses for payment of facility fees for network products, including any changes that were made to such policies within the last five years;

(II)

A list of common procedures associated with facility fees;

(III)

Each payer’s network product names;

(IV)

Paid aggregate facility fee billings from outpatient providers and the associated number of facility fee claims, broken down by hospital or health system; and

(V)

A description of the estimated impact of facility fees on premium rates, out-of-network claims, member cost sharing, and employer costs;

(d)

Data from independent health-care providers that are not affiliated with or owned by a hospital or health system, including:

(I)

Historic and current business names and addresses;

(II)

Historic and current tax identification numbers and national provider identifiers;

(III)

Facility fee billing policies, including whether any changes were made to such policies in the past five years; and

(IV)

Where applicable, the top ten CPT codes, revenue codes, or combination thereof, at the steering committee’s discretion, for which a facility fee is billed and the professional fee amount for the same service;

(e)

The impact of facility fees and payer coverage policies on the Colorado healthcare affordability and sustainability enterprise, created in section 25.5-4-402.4, the medicaid expansion, uncompensated care, and undercompensated care;

(f)

The impact of facility fees on access to care, including specialty care, primary care, and behavioral health care; integrated care systems; health equity; and the health-care workforce; and

(g)

A description of the way in which health-care providers may be paid or reimbursed by payers for outpatient health-care services, with or without facility fees, that explores any legal and historical reasons for split billing between professional and facility fees at:

(I)

On-campus locations;

(II)

Off-campus locations by health-care providers affiliated with or owned by a hospital or health system; and

(III)

Locations by independent health-care providers not affiliated with or owned by a hospital system.

(7)

To the extent feasible, data analyzed for purposes of subsection (6) of this section must be sourced from 2014 through 2022, as determined by the steering committee and third-party contractors, and shall be disaggregated by:

(a)

Year;

(b)

Hospital or health system, where applicable;

(c)

Type of service;

(d)

Facility site type, including on- or off-campus; and

(e)

Payer.

(8)

The steering committee may include in the report information received in accordance with this section; except that the steering committee shall not share publicly any information submitted to the steering committee that is confidential, is proprietary, contains trade secrets, or is not a public record pursuant to part 2 of article 72 of title 24 except in aggregated and de-identified form.

(9)

The data described in this section must be sought in a form and manner determined by the steering committee, state department, or third-party contractors to facilitate submission of information. The steering committee shall seek to exhaust existing data sources before making additional requests for information for purposes of the report, and every effort must be made to minimize the number of data requests. The report must include a description of which entities were contacted for information and the outcome of each request.

(10)

A statewide association of hospitals may also provide data specified in subsection (6)(b) of this section to the steering committee.

(11)

This section is repealed, effective January 1, 2025.

Source: Section 25.5-4-216 — Report on impact of hospital facility fees in Colorado - definitions - steering committee - repeal, https://leg.­colorado.­gov/sites/default/files/images/olls/crs2023-title-25.­5.­pdf (accessed Oct. 20, 2023).

25.5‑4‑101
Short title
25.5‑4‑102
Legislative declaration
25.5‑4‑103
Definitions
25.5‑4‑104
Program of medical assistance - single state agency
25.5‑4‑105
Federal requirements under Title XIX
25.5‑4‑106
Cooperation with federal government - grants-in-aid - cooperation with the state department of human services in delivery of services
25.5‑4‑107
Retaliation definition
25.5‑4‑201
Cash system of accounting - financial administration of medical services premiums - medical programs administered by department of human services - federal contributions - rules
25.5‑4‑203
Advisory council established
25.5‑4‑204
Automated medical assistance administration
25.5‑4‑205
Application - verification of eligibility - demonstration project - rules - repeal
25.5‑4‑205.5
Confined persons - suspension of benefits
25.5‑4‑206
Reimbursement to counties - costs of administration
25.5‑4‑207
Appeals - rules - applicability
25.5‑4‑208
County duties - transitional medicaid
25.5‑4‑209
Payments by third parties - copayments by recipients - review - appeal - children’s waiting list reduction fund - rules - repeal
25.5‑4‑210
Purchase of health insurance for recipients
25.5‑4‑211
Medicaid management information system - appropriation in annual general appropriation act - expenditure in next fiscal year
25.5‑4‑212
Medicaid client correspondence improvement process - legislative declaration - definition
25.5‑4‑213
Audit of medicaid client correspondence - definition
25.5‑4‑215
Study - benefits for persons on work release - repeal
25.5‑4‑216
Report on impact of hospital facility fees in Colorado - definitions - steering committee - repeal
25.5‑4‑300.4
Last resort for payment - legislative intent
25.5‑4‑300.7
Prevention of coding errors - prepayment review of claims
25.5‑4‑300.9
Explanation of benefits - medicaid recipients - legislative declaration
25.5‑4‑301
Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures - repeal
25.5‑4‑302
Recovery of assets
25.5‑4‑303
State income tax refund intercept - garnishment of earning - failure to provide medical support for child
25.5‑4‑303.3
Provider fraud - attorney general report
25.5‑4‑303.5
Short title
25.5‑4‑304
Definitions
25.5‑4‑305
False medicaid claims - liability for certain acts
25.5‑4‑306
Civil actions for false medicaid claims
25.5‑4‑307
False medicaid claims procedures - statute of limitations
25.5‑4‑308
False medicaid claims jurisdiction
25.5‑4‑309
False medicaid claims civil investigation demands
25.5‑4‑310
Medicaid false claims report
25.5‑4‑401
Providers - payments - rules
25.5‑4‑401.2
Performance-based payments - reporting - repeal
25.5‑4‑401.5
Review of provider rates - advisory committee - recommendations - repeal
25.5‑4‑402
Providers - hospital reimbursement - hospital review program - rules
25.5‑4‑402.4
Hospitals - healthcare affordability and sustainability fee - legislative declaration - Colorado healthcare affordability and sustainability enterprise - federal waiver - fund created - rules - reports - repeal
25.5‑4‑402.5
Providers - state university teaching hospitals
25.5‑4‑402.8
Hospital transparency report - definitions
25.5‑4‑403
Providers - behavioral health safety net providers - reimbursement
25.5‑4‑403.1
Providers - community mental health centers - cost reporting
25.5‑4‑404
Payments for clinic services - restrictions on use
25.5‑4‑405
Mental health managed care service providers - requirements
25.5‑4‑406
Rate setting - medicaid residential treatment service providers - monitoring and auditing - report
25.5‑4‑407
Services by licensed psychologists without a doctor’s referral
25.5‑4‑408
Services provided by licensed psychologists - cost containment program
25.5‑4‑409
Authorization of services - nurse anesthetists - advanced practice registered nurses
25.5‑4‑410
Services of audiologists and speech pathologists without supervision
25.5‑4‑411
Authorization of services provided by dental hygienists
25.5‑4‑412
Family planning services - family-planning-related services - rules - definitions
25.5‑4‑413
Certain providers to inform patients of rights concerning advance medical directives
25.5‑4‑414
Providers - physicians - prohibition of certain referrals - definitions
25.5‑4‑415
No public funds for abortion - exception - definitions - repeal
25.5‑4‑416
Providers - medical equipment and supplies - requirements
25.5‑4‑417
Provider fee - medicaid providers - state plan amendment - rules - definitions
25.5‑4‑420
Providers to obtain unique NPI - service site - provider type - definitions
25.5‑4‑422
Cost control - legislative intent - use of technology - stakeholder feedback - reporting - rules
25.5‑4‑423
Targets for investments in primary care
25.5‑4‑425
Providers - health-care services related to labor and delivery - reimbursement
25.5‑4‑427
Supplemental state payment to the Denver health and hospital authority - repeal
25.5‑4‑428
Prior authorization for a step-therapy exception - rules - definition
25.5‑4‑429
Hospital and provider billing requirements - description of service provided - rules
25.5‑4‑430
Increasing access to behavioral health care for children and youth - directed payment authority - fee schedule rates
25.5‑4‑503
Waiver applications - authorization
25.5‑4‑505
Federal authorization related to persons involved in the criminal justice system - assessment - report - repeal
25.5‑4‑506
Coverage for doula services - stakeholder process - federal authorization - scholarship program - training - report - definitions - repeal
Green check means up to date. Up to date

Current through Fall 2024

§ 25.5-4-216’s source at colorado​.gov