Chapter 10. Maryland Trauma Physician Services Fund
Regulation .01 Scope.LinkCopy Citation
A.
This chapter applies to trauma physicians, trauma health care practitioners, and Maryland Institute for Emergency Medical Services Systems designated trauma centers, Specialty Referral Centers, and rehabilitation hospitals that are affiliated with Maryland Institute for Emergency Medical Services Systems designated trauma centers by common ownership, as defined in Health-General Article, §19-130(a)(3) and (4), Annotated Code of Maryland, that provide trauma care.
B.
Reimbursement.
(1)
Trauma physicians or trauma health care practitioners seeking reimbursement for uncompensated care provided to trauma patients shall file a claim pursuant to this chapter to receive reimbursement from the Maryland Trauma Physician Services Fund.
(2)
Trauma physicians or trauma health care practitioners seeking reimbursement for trauma care provided to trauma patients enrolled in the Maryland Medical Assistance Program at the elevated rate shall comply with special billing requirements pursuant to this chapter.
(3)
Trauma centers seeking reimbursement for costs of maintaining trauma physicians on-call shall file a claim to receive reimbursement from this Fund.
(4)
Trauma centers seeking reimbursement for standby costs shall file a claim to receive reimbursement from this Fund.
(5)
Trauma centers seeking trauma grants shall file an application to receive a grant from this Fund in accordance with a process and guidelines developed by the Maryland Health Care Commission.
Regulation .02 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Applicant” means a person or entity eligible to file a claim to receive reimbursement from the Fund.
(2)
“Commission” means the Maryland Health Care Commission.
(3)
“Faculty practice plan” means a professional services organization that:
(a)
Includes physicians; and
(b)
Is formed to carry out, improve, and supplement the medical education, research, and clinical services program of a medical school.
(4)
“Fraud” means knowingly and willfully making or causing to be made any false statement or representation of a material fact:
(a)
In a claim for payment; or
(b)
In determining eligibility for payments.
(5)
“Fund” means the Maryland Trauma Physician Services Fund.
(6)
“HSCRC” means the Health Services Cost Review Commission.
(7)
“Maryland Trauma Registry” means a clinical trauma registry maintained by MIEMSS that:
(a)
Monitors and provides information necessary to evaluate major trauma or specialty patient care, outcome, and cost; and
(b)
Assesses how designated trauma centers and other hospitals comply with the trauma standards, regulations, and protocols.
(8)
Medicaid.
(a)
“Medicaid” means the Maryland Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396, et seq. and the Children and Families Health Care Program under Title XXI of §4901 of the Balanced Budget Act of 1997, that provide comprehensive medical and other health-related care for indigent and medically indigent persons.
(b)
“Medicaid” includes the services provided by a managed care organization under the State waiver program authorized under §1115 of the Social Security Act, 42 U.S.C. §1396n.
(9)
“Medicaid differential” means the difference in reimbursement between Medicare and Medicaid for trauma services provided by a trauma physician or trauma health care practitioner to a Medicaid trauma patient in a trauma center.
(10)
“Medicare economic index (MEI)” means the federal Centers for Medicare and Medicaid Services' measure of inflation in the inputs for providing physician services.
(11)
“MIEMSS” means the Maryland Institute for Emergency Medical Services Systems.
(12)
On-Call Physician.
(a)
“On-call physician” means a trauma physician who commits for a specific time period to be available and respond within a certain amount of time, as defined by MIEMSS, to provide care for a trauma patient in the trauma center.
(b)
“On-call physician” does not include a physician on standby in a trauma center.
(13)
On-Call Costs.
(a)
“On-call costs” means the costs to a trauma center to have trauma physicians available and ready to respond to trauma patients within a certain amount of time, as defined by MIEMSS.
(b)
“On-call costs” does not include standby costs.
(14)
“On-call services application” means the difference in reimbursement between Medicare and Medicaid for trauma services provided by a trauma physician or trauma health care practitioner to a Medicaid trauma patient in a trauma center.
(15)
“Reasonable compensation equivalent (RCE)”:
(a)
Is a methodology established by Medicare to set limits on what a hospital may claim per physician specialty standby hour; and
(b)
Has the meaning described in 68 FR 45458 (Aug. 1, 2003).
(16)
Service Period.
(a)
“Service period” means the time that trauma services are provided from entrance to the trauma center until dismissal or discharge from the trauma center.
(b)
“Service period” includes a subsequent readmission or outpatient visit to the trauma center, or trauma center-affiliated acute care general hospital, for services that are directly related to the initial trauma injury.
(c)
“Service period” includes a subsequent admission or outpatient visit to a trauma center-affiliated rehabilitation hospital, or rehabilitation unit of a trauma center.
(17)
“Specialty referral center” means:
(a)
The Curtis National Hand Center at Union Memorial Hospital;
(b)
The Eye Trauma Center at the Wilmer Eye Institute at The Johns Hopkins Hospital; and
(c)
The Johns Hopkins Health System Burn Program.
(18)
“Standby costs” means costs to a trauma center for paying physicians to be available on site at the trauma center to treat trauma patients.
(19)
Trauma Center.
(a)
“Trauma center” means a hospital designated by the Maryland Institute for Emergency Medical Services Systems (MIEMSS) as:
(i)
The State primary adult resource center;
(ii)
A Level I trauma center;
(iii)
A Level II trauma center;
(iv)
A Level III trauma center;
(v)
A pediatric trauma center; or
(vi)
A specialty referral center as defined in §B(17) of this regulation.
(b)
“Trauma center” includes a pediatric trauma center that has entered into an agreement with MIEMSS.
(20)
“Trauma health care practitioner” means a health care practitioner licensed under the Health Occupations Article who provides care in a trauma center-affiliated general acute care hospital or in a trauma center-affiliated rehabilitation hospital during the service period to trauma patients on the Maryland Trauma Registry as defined by the Maryland Institute for Emergency Medical Services Systems (MIEMSS).
(21)
“Trauma patient” means a patient whose trauma services are documented in the Maryland Trauma Registry.
(22)
“Trauma physician” means a physician who provides care in a trauma center, trauma center-affiliated general acute care hospital, or in a trauma center-affiliated rehabilitation hospital during the service period to a trauma patient on the Maryland Trauma Registry as defined by the Maryland Institute for Emergency Medical Services Systems (MIEMSS).
(23)
“Trauma services” means trauma care provided to a trauma patient in a trauma center, trauma center-affiliated general acute care hospital, trauma center-affiliated rehabilitation hospital, or rehabilitation unit of a trauma center.
(24)
“Uncompensated care” means trauma services provided by a trauma physician or trauma health care practitioner to a trauma patient on the Maryland Trauma Registry who:
(a)
Has no health insurance, including private health insurance, Medicare Part B coverage, VA health benefits, or CHAMPUS;
(b)
Is not covered by Workers' Compensation coverage;
(c)
Is not eligible for Medical Assistance coverage; and
(d)
Has not paid the full Medicare reimbursement for the trauma care received, even after documented attempts by the trauma physician or trauma health care practitioner to obtain payment.
(25)
“Uncompensated care shortfall” means the difference in reimbursement between what Medicare pays and what the trauma physician providing care collects from the uncompensated care trauma patient.
(26)
“Uncompensated services claim” means a CMS 1500 form or an ANSI 837 electronic transaction completed according to Commission specifications and submitted for reimbursement of uncompensated care services.
Regulation .03 Fund Administration.LinkCopy Citation
A.
The Fund is a special, nonlapsing interest bearing fund that is not subject to State Finance and Procurement Article, §7-302, Annotated Code of Maryland.
B.
The purpose of the Fund is to subsidize the documented costs:
(1)
Of uncompensated care incurred by a trauma physician or trauma health care practitioner in providing trauma services to a trauma patient on the Maryland Trauma Registry;
(2)
Of undercompensated care incurred by a trauma physician or trauma health care practitioner in providing trauma services to an enrollee of the Medicaid Program who is a trauma patient on the Maryland Trauma Registry;
(3)
Incurred by a trauma center to maintain trauma physicians on-call as required by MIEMSS;
(4)
Incurred by a trauma center to maintain patient education, equipment, services, systems, and training as required by MIEMSS, for trauma-related care and not otherwise reimbursed; and
(5)
Incurred by the Commission to administer the Fund and audit reimbursement requests and trauma grants to assure appropriate payments are made from the Fund.
C.
Administering Agencies. The Commission shall administer the disbursements from the Fund.
D.
Interest. The interest on the Fund shall be accounted for separately and credited to the Fund, and is not subject to State Finance and Procurement Article, §6-226(a), Annotated Code of Maryland.
Regulation .04 Source of Fund Revenue.LinkCopy Citation
A.
The Fund consists of motor vehicle registration surcharges paid into the Fund in accordance with Transportation Article, §§13-954(b), and 21-902, Annotated Code of Maryland, and regulations promulgated under that authority, and any other money transferred from the General Fund of the State.
B.
The Commission shall make reimbursement from the Fund for:
(1)
On-call costs;
(2)
Uncompensated care costs;
(3)
Medicaid differential payments;
(4)
Standby expenses to an out-of-State pediatric trauma center that has entered into an agreement with the Maryland Institute for Emergency Medical Services Systems;
(5)
Grants that may cover costs of trauma centers for trauma related expenses, including physician standby, patient education, equipment, services, systems, training, and other MIEMSS-required incremental trauma costs not otherwise reimbursed; and
(6)
The Commission's administrative expenses including:
(a)
The adjudication of uncompensated trauma claims;
(b)
The audit of providers receiving uncompensated care trauma payments, Medicaid trauma payments, and on-call payments;
(c)
The audit of managed care organizations payments to trauma physicians and trauma health care practitioners;
(d)
Enhancements of the MIEMSS Trauma Registry; and
(e)
Commission personnel costs associated with administering the Fund.
Regulation .05 Who May Request Payment.LinkCopy Citation
A.
A trauma physician or trauma health care practitioner as defined in Regulation .02 of this chapter may request payment under this chapter.
B.
Medicaid and Uncompensated Care Reimbursement.
(1)
Trauma Practitioner Services. A faculty practice plan, a physician practice, a trauma center on behalf of the trauma physician or trauma health care practitioner, or an individual trauma physician or individual health care practitioner allowed to bill Medicaid may submit requests for payment for trauma services provided to a Medicaid trauma patient or for uncompensated care trauma services if:
(a)
Those services are provided to a trauma patient during the service period as defined in this chapter; and
(b)
The practitioner meets the definition of a trauma physician or trauma health care practitioner under Regulation .02 of this chapter.
(2)
Emergency Physician Services.
(a)
The total reimbursement from the Fund to emergency physicians practicing at any one trauma center may not exceed $300,000 annually.
(b)
An emergency room physician:
(i)
Is eligible for uncompensated care shortfall payments only; and
(ii)
May not receive Medicaid differential payments or on-call payments from the Fund.
C.
On-Call Payments. The following trauma centers may apply for on-call payments:
(1)
A MIEMSS-designated Level I trauma center or pediatric trauma center;
(2)
Level II and Level III trauma centers; and
(3)
The Specialty Referral Centers.
D.
Standby Payments. An out-of-State pediatric trauma center that has entered into an agreement with MIEMSS may apply for an annual grant to subsidize standby costs.
Regulation .06 Payments for Medicaid Trauma Patients.LinkCopy Citation
A.
A trauma physician or trauma health care practitioner:
(1)
Is eligible for payment from the Fund for trauma services provided to a Medicaid trauma patient on the Maryland Trauma Registry on or after July 1, 2024; and
(2)
May seek reimbursement in accordance with this regulation.
B.
A trauma physician or trauma health care practitioner providing trauma services to a Medicaid trauma patient during the service period shall be reimbursed at the greater of:
(1)
The Medicaid routine payment rate; or
(2)
Up to 100 percent of the current Medicare facility-based payment in the Baltimore carrier locality area.
C.
To be eligible for the Medicaid differential payment described in §B of this regulation, diagnosis codes shall meet one of the following two conditions:
(1)
A diagnosis code shall fall between 800.00 — 959.9; or
(2)
If a diagnosis code does not fall between 800.0 — 959.9, a supplementary classification of external causes of injury and poisoning (E800 — E999) shall appear as a secondary diagnosis code.
D.
An organization billing on behalf of trauma physicians or trauma health care practitioners eligible for Medicaid differential payments shall designate a trauma service by using the appropriate code in the CPT Modifier field on the electronic claim or on the paper CMS 1500 in accordance with Medicaid claims submission requirements.
E.
To be eligible for the Medicaid differential payment described in §B of this regulation, the place of service code shall have one of the following values:
(1)
Appropriate code to indicate “acute care inpatient hospital”;
(2)
Appropriate code to indicate “outpatient hospital”;
(3)
Appropriate code to indicate “emergency room”; or
(4)
Appropriate code to indicate “inpatient rehabilitation hospital”.
F.
The Maryland Department of Health may apply Medicaid payment rules when adjudicating claims for trauma services to trauma patients.
G.
The Fund shall transfer to the Maryland Department of Health an amount sufficient to fully cover the State's share of expenditures for Medicaid differential payments for that fiscal year.
Regulation .07 Payments for Uncompensated Care Patients.LinkCopy Citation
A.
A trauma physician or trauma health care practitioner:
(1)
Is eligible for payment from the Fund for trauma services provided to uncompensated trauma care patients with an admission date on the Maryland Trauma Registry beginning on or after July 1, 2024; and
(2)
May seek reimbursement in accordance with this regulation.
B.
The cost of uncompensated care incurred by a trauma physician or trauma health care practitioner in providing trauma care to a trauma patient as defined in this chapter shall be reimbursed at a rate of up to 100 percent of the current Medicare facility-based payment for a service in the Baltimore carrier locality area, less any amount for trauma physician or trauma health care practitioner services paid by the patient or other third-party payors including, but not limited to, auto insurance, criminal injuries compensation fund, attorneys, or collection agencies, as reported to the Fund on the uncompensated services claim.
C.
An organization billing on behalf of trauma physicians or trauma health care practitioners eligible for uncompensated care payments shall:
(1)
Designate a trauma service by appropriate coding of the CPT Modifier on the electronic ANSI 837 transaction or paper CMS 1500 claim in accordance with claims submission requirements; and
(2)
Include the patient's trauma registry number on the electronic claim or on the CMS 1500.
D.
Diagnosis Code.
(1)
Except as provided in §D(2) of this regulation, a diagnosis code shall fall between 800.00 — 959.9.
(2)
If a diagnosis code does not fall between 800.0 — 959.9, a supplementary classification of external causes of injury and poisoning (E800 — E999) shall appear as a secondary diagnosis code.
E.
To be eligible for uncompensated care differential payment described in §B of this regulation, the place of service code shall have one of the following values:
(1)
Appropriate code for “acute care inpatient hospital”;
(2)
Appropriate code for “outpatient hospital”;
(3)
Appropriate code for “emergency room”; or
(4)
Appropriate code for “rehabilitation hospital”.
F.
The uncompensated services claim shall:
(1)
Document uncompensated care services not previously claimed under the Fund;
(2)
Exclude services for trauma patients who have applied for assistance through Medicaid, but who have not received a final eligibility determination;
(3)
Exclude noncovered services that the trauma physician or trauma health care practitioner provided to trauma patients covered by health insurance;
(4)
Exclude services for trauma patients covered by health insurance for which the trauma physician or trauma health care practitioner failed to comply with the insurer's coverage rules or claim filing requirements; and
(5)
Have a date of service on the claim not older than 5 years.
G.
Uncompensated care services are eligible for reimbursement from the Fund only after a faculty practice plan, a physician practice, a trauma center on behalf of a trauma physician or trauma health care practitioner, an individual trauma physician or an individual trauma health care practitioner has completed its collection efforts using the respective entity's documented policies and procedures.
H.
Order of Preference.
(1)
To minimize administrative costs in administering the Fund, the order of preference for the entity submitting an uncompensated services claim is as follows:
(a)
Faculty practice plan;
(b)
Physician practice;
(c)
Trauma physician;
(d)
Individual trauma health care practitioner.
(2)
The preference specified in §H(1) of this regulation refers to the submitting entity and not the preference for distributing payments.
I.
A trauma patient treated at an out-of-State pediatric trauma center that has entered into an agreement with MIEMSS shall be a Maryland resident in order for the trauma physician or trauma health care practitioner to file an uncompensated services application for an uncompensated care shortfall payment. The determination of whether a trauma patient is a Maryland resident shall be based on the trauma patient's demographic information as listed on the Maryland Trauma Registry.
J.
The uncompensated services claim shall contain the following information:
(1)
The name and federal tax identification number of the trauma physician or trauma health care practitioner rendering the care;
(2)
The date of the service;
(3)
Appropriate codes describing the service;
(4)
Any amount recovered for the service rendered;
(5)
The name of the trauma patient;
(6)
The trauma patient's Maryland Trauma Registry number;
(7)
Date of the original trauma injury;
(8)
The diagnosis codes that were treated;
(9)
The procedure and service codes performed; and
(10)
Other information requested in the claim.
K.
The Commission, in consultation with the Health Services Cost Review Commission, may establish a payment rate for uncompensated care incurred by a trauma physician or trauma health care practitioner in providing trauma care to trauma patients that is above the 100 percent of Medicare payment for the service if:
(1)
The Commission determines that increasing the payment rate above 100 percent of the Medicare payment for the service will address an unmet need in the State trauma system;
(2)
The source of revenue increases and the projected current uses of the Fund decline;
(3)
The Commission considers data analyses of trauma care rendered at Maryland trauma centers for CPT codes reimbursed as uncompensated care as reported to the Maryland Medical Care Data Base; and
(4)
The Commission reports on its intention to increase the payment rate to the Senate Finance Committee and the House Health and Government Operations Committee, at least 60 days before any adjustment to the rate.
Regulation .08 On-Call Payment.LinkCopy Citation
A.
Eligibility. The Fund will reimburse trauma centers' on-call costs to maintain surgeons on-call in conformance with MIEMSS' regulations at COMAR 30.08.05 — 30.08.14 for the minimum number of trauma physicians required to be on-call. Trauma centers are eligible for on-call payments as follows:
(1)
The Level I trauma center and pediatric trauma center are eligible for on-call payments for on-call hours provided by trauma specialties designated in §B of this regulation on or after July 1, 2024;
(2)
Level II trauma centers are eligible for on-call payments for on-call hours provided by trauma specialties designated in §C of this regulation;
(3)
Level III trauma centers are eligible for on-call payments for on-call hours provided by trauma specialties designated in §D of this regulation; and
(4)
Specialty Referral Centers are eligible for on-call payments for on-call hours provided by trauma specialties designated in §E of this regulation on or after July 1, 2024.
B.
To determine the amount of on-call payments to a Level I trauma center or pediatric trauma center from the Fund, the following apply:
(1)
The cost incurred by a Level I trauma center or pediatric trauma center to maintain trauma surgeons, pediatric trauma surgeons, neurosurgeons, and orthopedic surgeons on-call when a post-graduate resident, who meets MIEMMS’ requirements under COMAR 30.08.05.07, is attending shall be reimbursed at the lesser of a trauma center's actual on-call costs, or up to 60 percent of the reasonable compensation equivalent's hourly rate for the specialty, inflated to the current year by the physician compensation component of the Medicare Economic Index as designated by the Centers for Medicare and Medicaid Services;
(2)
A Level I trauma center shall be eligible for a maximum 4,380 on-call hours each fiscal year beginning July 1, 2024; and
(3)
A pediatric trauma center shall be eligible for a maximum 4,380 on-call hours each fiscal year beginning July 1, 2024.
C.
To determine the amount of on-call payments to a Level II trauma center from the Fund, the following apply:
(1)
The cost incurred by a Level II trauma center to maintain trauma surgeons, neurosurgeons, and orthopedic surgeons on-call shall be reimbursed at the lesser of a trauma center's actual on-call costs or up to 60 percent of the reasonable compensation equivalent's hourly rate for the specialty, inflated to the current year by the physician compensation component of the Medicare Economic Index as designated by the Centers for Medicare and Medicaid Services; and
(2)
A Level II trauma center shall be eligible for a maximum 26,280 on-call hours each fiscal year beginning July 1, 2024.
D.
To determine the amount of on-call payments to a Level III trauma center from the Fund, the following apply:
(1)
The cost incurred by a Level III trauma center to maintain anesthesiologists, neurosurgeons, orthopedic surgeons, and trauma surgeons on-call shall be reimbursed at the lesser of a trauma center's actual on-call costs or up to 60 percent of the reasonable compensation equivalents hourly rate for the specialty, inflated to the current year by the physician compensation component of the Medicare Economic Index as designated by the Centers for Medicare and Medicaid Services;
(2)
A Level III trauma center shall be eligible for a maximum 35,040 on-call hours each fiscal year beginning July 1, 2024.
E.
To determine the amount of on-call payments to a Specialty Referral Center from the Fund, the following apply:
(1)
The cost incurred by a Specialty Referral Center to maintain trauma surgeons on-call for the Johns Hopkins Health System Burn Program shall be reimbursed at the lesser of the trauma center's actual on-call costs or up to 60 percent of the reasonable compensation equivalent's hourly rate for the specialty, inflated to the current year by the physician compensation component of the Medicare Economic Index as designated by the Centers for Medicare and Medicaid Services;
(2)
The cost incurred by a Specialty Referral Center to maintain trauma surgeons on-call for the Eye Trauma Center at the Wilmer Eye Institute at The Johns Hopkins Hospital, the cost incurred to maintain ophthalmologists on-call shall be reimbursed at the lesser of the trauma center's actual on-call costs or up to 60 percent of the reasonable compensation equivalent's hourly rate for the specialty, inflated to the current year by the physician compensation component of the Medicare Economic Index as designated by the Centers for Medicare and Medicaid Services;
(3)
The cost incurred by a Specialty Referral Center to maintain trauma surgeons on-call for the Curtis National Hand Center at Union Memorial Hospital, shall be reimbursed at the lesser of the trauma center's actual on-call costs or up to 60 percent of the reasonable compensation equivalent's hourly rate for the specialty, inflated to the current year by the physician compensation component of the Medicare Economic Index as designated by the Centers for Medicare and Medicaid Services; and
(4)
A Specialty Referral Center trauma center shall be eligible for a maximum 2,190 hours of trauma on-call per fiscal year, beginning July 1, 2024.
F.
The trauma center shall apply for payment from the Fund by submitting a semiannual on-call services application within 30 days after the end of the reporting cycle.
G.
The on-call services application shall list on-call costs paid to trauma physicians at the trauma center during the reporting cycle. The on-call services application shall contain the following information:
(1)
The name and trauma level of the trauma center;
(2)
The name of each trauma physician providing on-call coverage;
(3)
The specialty of each trauma physician providing on-call coverage;
(4)
The amount of time available on-call for each physician;
(5)
The amount paid in on-call stipends to each physician; and
(6)
Any other information required by the Commission to validate the claim.
H.
The Commission may increase the hours and percent of RCE specified in this regulation in accordance with Health General § 19-130, Annotated Code of Maryland.
Regulation .09 Payment for Costs at a Pediatric Center.LinkCopy Citation
A.
The pediatric trauma centers listed below shall be eligible for an annual grant of up to $900,000 for documented expenses related to the provision of trauma care to Maryland residents:
(1)
Johns Hopkins Children’s Center; and
(2)
Children’s National Medical Center.
B.
Pediatric trauma centers shall submit an application for documented expenses incurred in the previous fiscal year using guidelines developed by the Health Services Cost Review Commission.
C.
The pediatric trauma center shall submit the application for its previous fiscal year to the Commission within 45 days after the end of that fiscal year.
Regulation .10 Trauma Equipment Grants.LinkCopy Citation
A.
Eligibility.
(1)
The Commission, in consultation with the Health Services Cost Review Commission and the Maryland Institute for Emergency Medical Services Systems, shall develop a process for the award of grants to Level I, Level II and Level III trauma centers to be used in the delivery of trauma care.
(2)
The process developed by the Commission for the award of grants shall include:
(a)
Grant applications and review and selection criteria for the award of grants;
(b)
Review by the Commission, if necessary, for any project that exceeds Certificate of Need thresholds; and
(c)
Any other procedure determined necessary by the Commission.
B.
The Commission may issue grants from any balance carried over to the Fund from prior fiscal years.
C.
The total amount of grants awarded in a fiscal year may not reduce the balance remaining in the Fund at the end of the fiscal year to less than 15 percent of the revenue collected in that fiscal year.
D.
Before awarding grants under this regulation in a fiscal year, the Commission shall report to the Senate Finance Committee and the House Health and Government Operations Committee on the process that the Commission has developed for awarding grants in that fiscal year.
Regulation .11 Equitable Payment Under the Fund.LinkCopy Citation
A.
Disbursement from the Fund is subject to the availability of funds.
B.
The Commission shall adjust reimbursement formulas used for Medicaid trauma services, uncompensated care trauma services, on-call payments, and standby payments to a pediatric trauma center to preserve the distribution of monies in the Fund.
C.
Revenue; Payments.
(1)
On or before May 1 of each year, the Commission shall determine appropriate levels of payment that can be sustained for the upcoming fiscal year beginning July 1, given the expected revenue in the Fund.
(2)
If expected revenue in the Fund is insufficient to meet expected payments, the Medicaid differential payments, uncompensated care shortfall payments, trauma center on-call payments, and standby payments to a pediatric trauma center shall be adjusted by the same rate to maintain solvency in the Fund.
(3)
The Commission shall maintain a sufficient balance in the Fund to assure equitable payments across a fiscal year.
(4)
If Fund payments require adjustment, the Commission shall report to the trauma centers and the trauma physicians listed on trauma center rosters the expected payment levels for the upcoming State fiscal year by June 30.
D.
If the Commission estimates that operating shortfalls will occur during a fiscal year and that those shortfalls will be sufficiently large that the annual update process cannot be used, the Commission shall use the following conventions:
(1)
On-call payments for the next semiannual reporting period shall be adjusted to preserve solvency in the Fund;
(2)
Priority for meeting the funding needs of Level III trauma centers to maintain physicians shall be maintained;
(3)
The Commission may not change Medicaid reimbursement during a fiscal year, unless a 4-month notice is provided to the Medicaid program and the uncompensated care and on-call payments have already been halted; and
(4)
The Commission shall adjust Medicaid reimbursements during subsequent annual update processes to adjust for any inequities that arise due to implementation of §D(3) of this regulation during the preceding fiscal year.
Regulation .12 Filing of On-call Applications and Uncompensated Care Claims.LinkCopy Citation
A.
In order to receive a payment from the Fund for uncompensated care, a faculty practice plan, a physician practice, a trauma physician, a trauma health care practitioner, or a trauma center on behalf of a trauma physician or trauma health care practitioner shall submit a timely and complete uncompensated services claim that includes the information required in this chapter on a form and in a manner approved by the Commission as indicated in the application.
B.
In order to receive a payment from the Fund for on-call costs, a faculty practice plan, a physician practice, a trauma physician, or a trauma center on behalf of a trauma physician, shall submit a timely and complete on-call services application that includes the information required in this chapter on a form and in a manner approved by the Commission as indicated in the application.
C.
A faculty practice plan, a physician practice plan, a trauma center, or a trauma physician that does not file an on-call services application within the time frame specified is not eligible for participation in the Fund for that time period.
D.
An on-call services application that is substantially incomplete or inaccurate may be considered not filed.
Regulation .13 Audits.LinkCopy Citation
A.
The Commission, or its designee, may audit to verify the information submitted by faculty practice plans, physician practices, trauma physicians, trauma health care practitioners, and trauma centers applying for grants or reimbursement from the Fund.
B.
The Commission, or its designee, may perform on-site audits.
C.
A person who has submitted an application for a grant or reimbursement from the Fund shall provide the Commission, or its designee, with access to all information, documents, and facilities requested by the Commission, or its designee, for purposes of auditing the person’s application.
D.
Information discovered by the audit process indicating that an application for payment from the Fund was improperly paid may result in remedial action being taken, including but not limited to, denial or partial denial of future payments from the Fund, referral to the State of Maryland, Central Collections Unit, or other appropriate action.
Regulation .14 Appeals.LinkCopy Citation
A.
The Commission's executive director, or designee, shall review any appeal from an audit finding, a denial, or partial denial, of an uncompensated care shortfall payment, an on-call payment or grant award.
B.
To secure review of an audit finding, denial, or partial denial, an applicant shall file a written appeal of the denial with the Commission, together with any supporting memoranda and documentation, within 15 days of the date of receipt of audit finding, the denial, or the partial denial, from the Fund.
C.
In reviewing an audit finding, a denial, or a partial denial, of an uncompensated care shortfall payment, on-call payment or grant award, the executive director, or designee, shall consider all relevant factors and render a decision upon the written information, without an oral hearing, in a timely fashion. The executive director, or designee, may seek and consider further information from the applicant or supplementation of the application, if necessary or appropriate.
Regulation .15 Annual Reconciliation Reporting Requirements.LinkCopy Citation
A.
On or before January 31 of each year, a trauma physician or trauma health care practitioner who has received uncompensated care reimbursement from the Fund during the prior calendar year shall file an annual reconciliation report with the Commission.
B.
The annual reconciliation report shall include:
(1)
The name, address, and telephone number of the practitioner, practice, or center;
(2)
The name, address, and telephone number of the practitioner, practice, or center's contact person for the report;
(3)
The name of the trauma center where care was provided;
(4)
The amount of money recovered from another payer source for claims that had been reimbursed by the Fund, including:
(a)
The practitioner's name providing the care;
(b)
The patient's name, Trauma Registry number, Social Security number, dates of service, and total amount paid by the Trauma Fund;
(c)
The source of the additional funds received;
(d)
The amount of the other payment received; and
(e)
The amount returned to the Trauma Fund; and
(5)
A certification by an authorized designee of the practitioner, practice, or center that the facts stated in the annual reconciliation report are true and accurate.
Regulation .16 Prohibited Acts.LinkCopy Citation
A.
An applicant for payment from the Fund may not:
(1)
Make, or cause to be made, a false statement or false claim; or
(2)
Engage in fraud in submitting a claim or application.
B.
Violation of §A of this regulation may result in:
(1)
Referral to the appropriate Medicaid fraud administrative and prosecutorial authorities, to the Office of the State's Attorney, or both;
(2)
Rescission of, or an action for recovery of, any prior reimbursement improperly made by the Fund; and
(3)
Any other appropriate referrals or administrative action.
Regulation .17 Reporting Requirements to the General Assembly.LinkCopy Citation
On or before November 1 of each year, the Commission and the HSCRC shall report to the General Assembly in accordance with Health-General Article, §19-130(f) and State Government Article, §2-1246, Annotated Code of Maryland.
Regulation .18 Expiration of Fund.LinkCopy Citation
A.
This chapter remains in effect unless the Fund ceases to be funded or expires by operation of law.
B.
In the event the Fund ceases to operate, unless otherwise provided by law, the Fund shall make any final disbursements for the current reporting period based upon available funds.
Regulation .19 Effective Date.LinkCopy Citation
Trauma services provided by a trauma health care practitioner to a trauma patient on or after July 1, 2024, are eligible for reimbursement pursuant to the provisions set forth in this chapter.
Chapter annotations
Authority: Health-General Article, §§19-103(c), 19-130, and 19-207, Annotated Code of Maryland
History: Effective date:
History: Regulations .01 — .16 adopted as an emergency provision effective July 1, 2003 (30:19 Md. R. 1327); adopted permanently effective December 22, 2003 (30:25 Md. R. 1846)
History: Regulations .01 — .16 repealed and new regulations .01 — .17 adopted as an emergency provision effective July 1, 2006 (33:21 Md. R. 1672); adopted permanently effective October 23, 2006 (33:21 Md. R. 1676)
History: Regulations .01 — .17 repealed and new regulations .01—.19 adopted effective June 15, 2009 (36:12 Md. R. 837)
History: Regulation .01 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .02B amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .03B amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .04 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .05 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .06 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .07 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .08 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .09 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .10 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .11B, C amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .12 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .13 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .14A, C amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .15 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .16B amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .17 amended effective January 20, 2025 (52:1 Md. R. 18)
History: Regulation .19 amended effective January 20, 2025 (52:1 Md. R. 18)