by Jared Staheli
June 25th, 2015
If an IHS provider is unable to provide all the services a beneficiary that is a registered outpatient of the provider needs, the provider may provide those services “under arrangements”, via a contract with another entity. Section 1862(a)(14) of the Social Security Act prohibits payment for nonphysician services furnished to hospital inpatients and outpatients unless the services are furnished by the hospital either directly or under an arrangement. All services that are furnished by a hospital, either directly or under arrangement, to a registered hospital outpatient during a hospital encounter are subject to the hospital bundling requirements. 42 CFR 482.12(e) spells out the criteria for contracted services as they apply to a hospital’s COPS in the Medicare program. The IHS provider’s governing body must be responsible for services furnished in the provider whether or not they are furnished under contracts. The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. The IHS provider must maintain a list of all contracted services, including the scope and nature of the services provided. Chapter 5, §10.3 of Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual sets forth general Under Arrangement guidelines. The provider must exercise professional responsibility over the arranged-for services rather than merely serving as a billing conduit.
In accord with the above-cited law, regulation, and policy, IHS providers are responsible for furnishing medically necessary services to their registered outpatients either directly or under arrangement. Service unbundling is prohibited; only the provider can bill for services furnished to its inpatients and outpatients. The CMS recommends that when services are provided under arrangements the contract should specify how much the IHS provider will pay for each contracted service. The entity furnishing the services under arrangements with the provider must agree to accept the IHS provider’s payment as payment in full, and may not charge the beneficiary for such services.
The Office of the Inspector General is authorized to impose a civil money penalty against any individual who knowingly and willingly presents, or causes to be presented, a bill or request for payment, for items or services furnished under Medicare, that is inconsistent with an arrangement under §1886(a)(1)(H) of the Social Security Act or is in violation of the requirement for an arrangement. See 42 CFR 1003 for more information on civil money penalties, assessments and exclusions.