[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR415.102]



[Page 795-796]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 415_SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING 

PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS

--Table of Contents

 

      Subpart C_Part B Carrier Payments for Physician Services to 

                       Beneficiaries in Providers

 

Sec. 415.102  Conditions for fee schedule payment for physician services 

to beneficiaries in providers.



    (a) General rule. If the physician furnishes services to 

beneficiaries in providers, the carrier pays on a fee schedule basis 

provided the following requirements are met:

    (1) The services are personally furnished for an individual 

beneficiary by a physician.

    (2) The services contribute directly to the diagnosis or treatment 

of an individual beneficiary.

    (3) The services ordinarily require performance by a physician.

    (4) In the case of radiology or laboratory services, the additional 

requirements in Sec. 415.120 or Sec. 415.130, respectively, are met.

    (b) Exception. If a physician furnishes services in a provider that 

do not meet the requirements in paragraph (a) of this section, but are 

related to beneficiary care furnished by the provider, the intermediary 

pays for those services, if otherwise covered. The intermediary follows 

the rules in Sec. Sec. 415.55 and 415.60 for payment on the basis of 

reasonable cost or PPS, as appropriate.

    (c) Effect of billing charges for physician services to a provider.

    (1) If a physician furnishes services that may be paid under the 

reasonable



[[Page 796]]



cost rules in Sec. 415.55 or Sec. 415.60, and paid by the 

intermediary, or would be paid under those rules except for the PPS 

rules in part 412 of this chapter, and under the payment rules for GME 

established by Sec. Sec. 413.75 through 413.83 of this chapter, neither 

the provider nor the physician may seek payment from the carrier, 

beneficiary, or another insurer.

    (2) If a physician furnishes services to an individual beneficiary 

that do not meet the applicable conditions in Sec. Sec. 415.120 

(concerning conditions for payment for radiology services) and 415.130 

(concerning conditions for payment for physician pathology services), 

the carrier does not pay on a fee schedule basis.

    (3) If the physician, the provider, or another entity bills the 

carrier or the beneficiary or another insurer for physician services 

furnished to the provider, as described in Sec. 415.55(a), CMS 

considers the provider to which the services are furnished to have 

violated its provider participation agreement, and may terminate that 

agreement. See part 489 of this chapter for rules governing provider 

agreements.

    (d) Effect of physician assumption of operating costs. If a 

physician or other entity enters into an agreement (such as a lease or 

concession) with a provider, and the physician (or entity) assumes some 

or all of the operating costs of the provider department in which the 

physician furnishes physician services, the following rules apply:

    (1) If the conditions set forth in paragraph (a) of this section are 

met, the carrier pays for the physician services under the physician fee 

schedule in part 414 of this chapter.

    (2) To the extent the provider incurs a cost payable on a reasonable 

cost basis under part 413 of this chapter, the intermediary pays the 

provider on a reasonable cost basis for the costs associated with 

producing these services, including overhead, supplies, equipment costs, 

and services furnished by nonphysician personnel.

    (3) The physician (or other entity) is treated as being related to 

the provider within the meaning of Sec. 413.17 of this chapter 

(concerning cost to related organizations).

    (4) The physician (or other entity) must make its books and records 

available to the provider and the intermediary as necessary to verify 

the nature and extent of the costs of the services furnished by the 

physician (or other entity).



[60 FR 63178, Dec. 8, 1995, as amended at 70 FR 47490, Aug. 12, 2005]