§ 1395xx. Payment of provider-based physicians and payment under certain percentage arrangements
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/usc/title-42/section-1395xxA research copy — for the controlling text, always check the official state or federal source. Not legal advice.
(a)Criteria; amount of payments
(1)The Secretary shall by regulation determine criteria for distinguishing those services (including inpatient and outpatient services) rendered in hospitals or skilled nursing facilities—
(A)which constitute professional medical services, which are personally rendered for an individual patient by a physician and which contribute to the diagnosis or treatment of an individual patient, and which may be reimbursed as physicians’ services under part B, and
(B)which constitute professional services which are rendered for the general benefit to patients in a hospital or skilled nursing facility and which may be reimbursed only on a reasonable cost basis or on the bases described in section 1395ww of this title.
(A)For purposes of cost reimbursement, the Secretary shall recognize as a reasonable cost of a hospital or skilled nursing facility only that portion of the costs attributable to services rendered by a physician in such hospital or facility which are services described in paragraph (1)(B), apportioned on the basis of the amount of time actually spent by such physician rendering such services.
(B)In determining the amount of the payments which may be made with respect to services described in paragraph (1)(B), after apportioning costs as required by subparagraph (A), the Secretary may not recognize as reasonable (in the efficient delivery of health services) such portion of the provider’s costs for such services to the extent that such costs exceed the reasonable compensation equivalent for such services. The reasonable compensation equivalent for any service shall be established by the Secretary in regulations.
(C)The Secretary may, upon a showing by a hospital or facility that it is unable to recruit or maintain an adequate number of physicians for the hospital or facility on account of the reimbursement limits established under this subsection, grant exceptions to such reimbursement limits as may be necessary to allow such provider to provide a compensation level sufficient to provide adequate physician services in such hospital or facility.
(b)Prohibition of recognition of payments under certain percentage agreements
(1)Except as provided in paragraph (2), in the case of a provider of services which is paid under this subchapter on a reasonable cost basis, or other basis related to costs that are reasonable, and which has entered into a contract for the purpose of having services furnished for or on behalf of it, the Secretary may not include any cost incurred by the provider under the contract if the amount payable under the contract by the provider for that cost is determined on the basis of a percentage (or other proportion) of the provider’s charges, revenues, or claim for reimbursement.
(2)Paragraph
(1)shall not apply—
(A)to services furnished by a physician and described in subsection (a)(1)(B) and covered by regulations in effect under subsection (a), and
(B)under regulations established by the Secretary, where the amount involved under the percentage contract is reasonable and the contract—
(i)is a customary commercial business practice, or
(ii)provides incentives for the efficient and economical operation of the provider of services.
(Aug. 14, 1935, ch. 531, title XVIII, § 1887, as added and amended Pub. L. 97–248, title I, §§ 108(a)[(1)], 109(a), Sept. 3, 1982, 96 Stat. 337, 338; Pub. L. 98–21, title VI, § 602(j), Apr. 20, 1983, 97 Stat. 165.)
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Cited by 16 sections · top 11
U.S. Code
statutes-at-large
- Public Law 97–448To make technical corrections in the Economic Recovery Tax Act of 1981 and certain other recent tax legislation
- Public Law 112–240Entitled the “American Taxpayer Relief Act of 2012”
- Public Law 101–508To provide for reconciliation pursuant to section 4 of the concurrent resolution on the budget for fiscal year 1991
- Public Law 98–21To assure the solvency of the Social Security Trust Funds, to reform the medicare reimbursement of hospitals, to extend the Federal supplemental compensation program, and for other purposes
- Public Law 97–248To provide for tax equity and fiscal responsibility, and for other purposes
14 references not yet in our index
- Aug. 14, 1935, ch. 531
- Pub. L. 97–248, title I
- 96 Stat. 337
- Pub. L. 98–21, title VI, § 602(j)
- 97 Stat. 165
- Pub. L. 98–21
- Pub. L. 97–248, § 109(a)(2)
- section 604(a)(1) of Pub. L. 98–21
- Pub. L. 97–248, title I, § 109(c)(1)
- 96 Stat. 339
- Pub. L. 97–248, title I, § 108(b)
- 96 Stat. 338
- Pub. L. 97–448, title III, § 309(a)(3)
- 96 Stat. 2408
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§ 1395xx
Payment of provider-based physicians and payment under certain percentage arrangements
Stat.×7
U.S.C.×6
Stat. Comp.×3
ActAug. 14, 1935, ch. 531
Pub. L.Pub. L. 97–248, title I
Stat.96 Stat. 337
Pub. L.Pub. L. 98–21, title VI, § 602(j)
Stat.97 Stat. 165
Cites 18 · showing 9Cited by 16 across 3 sources