July 17th, 2015
Medicare Part B payment otherwise payable to a beneficiary for the services of a physician or supplier who charges on a fee-for-service basis may be paid to an entity using the indirect payment procedure (IPP). Any entity registered in accordance with the instructions in Pub. 100-08, chapter 15, sections 15.7.9 through 184.108.40.206 and meets the following requirements can bill using the IPP:
• Provides coverage of the service under a complementary health benefit plan (this is, the coverage that the plan provides is complementary to Medicare and covers only the amount by which the Part B payment falls short of the approved charge for the service under the plan).
• Has paid the person who provided the service an amount (including the amount payable under the Medicare program) that the person accepts as full payment.
• Has the written authorization of the beneficiary (or of a person authorized to sign claims on the beneficiary’s behalf under 42 C.F.R. §424.36) to receive the Part B payment for the services for which the entity pays.
• Relieves the beneficiary of liability for payment for the service and will not seek any reimbursement from the beneficiary, his or her survivors, or estate.
• Submits any information CMS or the contractor may request, including an itemized physician or supplier bill, in order to apply the requirements under the Medicare program.
• Identifies and excludes from its requests for payment all services for which Medicare is the secondary payer.
Entities that satisfy all of the requirements above may include employers, unions, insurance companies, and retirement homes. They also may include health care prepayment plans, health maintenance organizations (HMOs), competitive medical plans, and Medicare Advantage organizations. The IPP permits a physician or supplier to file a single claim with the complementary insurer and receive full payment in a single payment, relieves the beneficiary of the need to file a claim, and protects the beneficiary against any financial liability for the service.
Because section 1842(h)(1) of the Social Security Act only permits “physicians and suppliers” to enter into participation agreements and because IPP entities do not meet the definition of a “supplier” as described in 42 C.F.R. §400.202, IPP entities cannot enter into a participation agreement (Form CMS-460) with Medicare. Therefore, IPP claims are paid at the non-participating physician/supplier rate, which is 95% of the physician fee schedule amount.
Payment under the IPP can only be made for covered Part B services. If an IPP entity submits a claim for a beneficiary’s service that has already been billed to Medicare (for example, the claim was submitted by a physician before the IPP entity submitted its claim), then Medicare cannot make payment to the IPP entity for that same service. Conversely, if a physician or supplier submits a claim for a beneficiary’s service that has already been billed to Medicare (for example, the claim was submitted by an IPP entity before the physician submitted his/her claim), then Medicare cannot make payment to the physician for that same service. Medicare payment can only be made once for a beneficiary’s specific service. Therefore, claims for services that have already been billed to Medicare shall be denied (with appeal rights) by Medicare’s contractors.
In addition, Medicare payment cannot be made under the IPP for services that are payable for a particular beneficiary under any other Part of Medicare. For example, if a beneficiary’s service is payable under Part C and a Medicare Advantage organization is also an IPP entity under 42 C.F.R. §424.66, then a Medicare Part B payment under the IPP cannot be made to that Medicare Advantage organization for that beneficiary’s service. In these types of dual or multiple enrollment situations, services that are payable under those other Parts of Medicare (e.g., Parts C or D) cannot also be billed and paid for under Part B. Therefore, IPP entities that submit Part B claims for services that are payable under another Part of Medicare (e.g., Part C or D) shall be denied (with appeal rights) by Medicare’s contractors.
Payment for IPP claims by Medicare is conditioned upon the claim and the underlying transaction complying with the Medicare laws, regulations, and program instructions applicable to IPP entities, and on the IPP entity’s continued compliance with the regulatory requirements described in 42 C.F.R. §424.66.