Correcting Unacceptable Payment Arrangements (Rev. 1931, Issued: 03-12-10

by  Find-A-Code
July 17th, 2015

A. Disseminating Information

From time to time, A/B MACs must disseminate through professional relations media information regarding the prohibition in §30.2.

A/MACs

The following language may be used by A/MACs or adapted for this purpose: The Medicare law prohibits us from paying benefits due a provider to another person or organization under an assignment, power of attorney, or any other arrangement whereby that other person or organization receives those payments directly. There are the following exceptions to this rule:

• CMS may pay a provider’s benefits (in the provider’s name) to a billing or collection agent, if:

o The agent receives the payment under an agency agreement with the provider;

o The agent’s compensation is not related in any way to the dollar amounts billed or collected;

o The agent’s compensation is not dependent upon the actual collection of payment;

o The agent acts under instructions which the provider may modify or revoke at any time; and

o The agent, in receiving payment, acts only in the providers’ behalf.

• CMS may pay the providers’ benefits in accordance with an assignment established by, or pursuant to the order of, a court of competent jurisdiction. A provider should notify us immediately if:

• CMS has been mailing its benefits to the address of another person or organization;

• The provider has given that other person or organization power of attorney or other advance authority to negotiate its benefit checks; and

• None of the above exceptions that would permit payment to another person or organization apply in the provider’s case.

A provider which hereafter enters into or continues such a prohibited payment arrangement may have its participation in the program terminated and its right to receive assigned payment for physician services revoked.

B/DME MACs

A B/DME MAC may use or adapt the following language for notification:

The Medicare law prohibits us from paying benefits due a physician or other supplier of health care items and services, to another person or organization, under a reassignment or power of attorney or under any other arrangement whereby that other person or organization receives those payments directly. There are the following exceptions to this rule:

• CMS may pay a physician’s or supplier’s employer under the terms of his/her employment.

• CMS may pay a hospital, clinic, or other facility for services furnished by the physician or supplier in the facility, in accordance with the physician’s or supplier’s agreement with the facility.

• CMS may pay a group practice prepayment plan, prepaid health plan, or

• HMO for services of physicians and suppliers associated with the plan.

• CMS may pay a physician, medical group, or other supplier for the technical component (TC) or professional component (PC) of diagnostic tests (other than clinical diagnostic tests) that are subject to the anti-markup payment limitation.

• CMS may pay the patient’s regular physician for services provided to his/her patients by another physician on an occasional, reciprocal basis

• At least until December 31, 1993, CMS may pay the patient’s regular physician for services of a locum tenens physician during the absence of the regular physician where the regular physician pays the locum tenens on a per diem or similar fee-for-time basis.

• CMS may pay a physician’s or supplier’s benefits in his/her name to a billing or collection agent, e.g., a medical bureau, if:

o The agent receives the payment under an agency agreement with the physician or supplier;

o The agent’s compensation is not related in any way to the dollar amounts billed or collected;

o The agent’s compensation is not dependent upon the actual collection of payment;

o The agent acts under instructions which the physician or supplier may modify or revoke at any time; and

o The agent, in receiving the payment, acts only on the physician’s or supplier’s behalf.

• CMS may pay a physician’s or supplier’s benefits in accordance with a reassignment established by, or pursuant to the order of, a court of competent jurisdiction. A physician or supplier should notify us immediately if:

• CMS has been mailing his/her benefits to the address of another person or organization;

• The physician has given that other person or organization power of attorney or other advance authority to negotiate the physician’s benefit checks; and

• None of the above exceptions which would permit payment to another person or organization apply in his/her case. A physician or other eligible recipient of assigned payment who hereafter enters into or continues such a prohibited payment arrangement may have the right to receive assigned payment revoked.

Pub 100-04 Medicare Claims Processing Manual

References:

Correcting Unacceptable Payment Arrangements (Rev. 1931, Issued: 03-12-10. (2015, July 17). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/correcting-unacceptable-payment-arrangements-rev-1931-issued-03-12-10-27268.html

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