| Managed Care On-Line News: Articles |
[Federal Register: January 9, 1998 (Volume 63, Number 6)]
[Proposed Rules]
[Page 1659-1728]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr09ja98-26]
[[Page 1659]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 411, 424, 435, and 455
[HCFA-1809-P]
RIN 0938-AG80
Medicare and Medicaid Programs; Physicians' Referrals to Health
Care Entities With Which They Have Financial Relationships
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Proposed rule.
-----------------------------------------------------------------------
SUMMARY: This proposed rule would incorporate into regulations the
provisions of sections 1877 and 1903(s) of the Social Security Act.
Under section 1877, if a physician or a member of a physician's
immediate family has a financial relationship with a health care
entity, the physician may not make referrals to that entity for the
furnishing of designated health services under the Medicare program,
unless certain exceptions apply. The following services are designated
health services:
Clinical laboratory services.
Physical therapy services.
Occupational therapy services.
Radiology services, including magnetic resonance imaging,
computerized axial tomography scans, and ultrasound services.
Radiation therapy services and supplies.
Durable medical equipment and supplies.
Parenteral and enteral nutrients, equipment, and supplies.
Prosthetics, orthotics, and prosthetic devices and
supplies.
Home health services.
Outpatient prescription drugs.
Inpatient and outpatient hospital services.
In addition, section 1877 provides that an entity may not present
or cause to be presented a Medicare claim or bill to any individual,
third party payer, or other entity for designated health services
furnished under a prohibited referral, nor may the Secretary make
payment for a designated health service furnished under a prohibited
referral.
Section 1903(s) of the Social Security Act extended aspects of the
referral prohibition to the Medicaid program. It denies payment under
the Medicaid program to a State for certain expenditures for designated
health services. Payment would be denied if the services are furnished
to an individual on the basis of a physician referral that would result
in the denial of payment for the services under Medicare if Medicare
covered the services to the same extent and under the same terms and
conditions as under the State plan.
This proposed rule incorporates these statutory provisions into the
Medicare and Medicaid regulations and interprets certain aspects of the
law. The proposed rule is based on the provisions of section 1903(s)
and section 1877 of the Social Security Act, as amended by section
13562 of the Omnibus Budget Reconciliation Act of 1993, and by section
152 of the Social Security Act Amendments of 1994.
This file has been provided for MCOL Subscribers only and may not be forwarded, redistributed, copied or published in any medium.