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Medicare program; determination of reasonable charges. Health Care Financing Administration. Interim final rule with
Abstract:
This final rule implements section 946 of the Omnibus Reconciliation Act of 1980 by amending our regulations concerning the payment of reasonable charges for services furnished under Part B of the Medicare program. Section 946 specifies that payment for medical or other health care services will be determined on the basis of the customary and prevailing charge screens in effect at the time the services are furnished. (Current regulations provide that payment will be determined on the basis of the screens in effect at the time a claim is submitted or a request for payment is made.) The statute also requires that, when services are furnished more than twelve months before the fee screen year (July 1-June 30) in which the claim is submitted, payment will be based on the customary and prevailing charge screens in effect for the fee screen year immediately preceding the one in which the claim is submitted. Thus, we will not go back further than the immediately preceding fee screen year to determine reasonable charges for claims filed after long delays.
Insights
Medicare payment rules for Part B services are updated to reflect the Omnibus Reconciliation Act of 1980. Payments will now be based on the charge screens in effect when services were rendered, not when the claim was submitted.
Area of Science:
- Health Policy
- Medical Economics
Background:
- Current Medicare Part B regulations determine payment based on charge screens at the time of claim submission.
- Section 946 of the Omnibus Reconciliation Act of 1980 mandates changes to these payment regulations.
Purpose of the Study:
- To implement Section 946 of the Omnibus Reconciliation Act of 1980.
- To amend regulations regarding reasonable charge payments for Medicare Part B services.
Main Methods:
- Amending existing regulations to align with statutory requirements.
- Establishing new criteria for determining the effective date of customary and prevailing charge screens.
Main Results:
- Payment for medical services under Medicare Part B will be based on charge screens effective at the time services are furnished.
- For services rendered over twelve months prior to claim submission, payment will use charge screens from the immediately preceding fee screen year.
Conclusions:
- The final rule ensures Medicare payments reflect the customary and prevailing charges at the time of service delivery.
- This change impacts how reasonable charges are calculated, particularly for delayed claims, by limiting the look-back period for fee screens.