Medicare_Carriers_Manual / 8025 / 8025

Why This Topic Matters

It helps readers understand how Medicare policy distinguishes provider costs from physician charges in lease or concession scenarios and how those costs may affect reimbursement calculations.

Article Sections

1. Effect of Physician's Assumption of Operating Costs (Lease or Concession Arrangement)

   Introduces Medicare reimbursement guidance for arrangements in which operating expenses are borne by a provider or by a physician. It frames the article’s focus on cost treatment and reasonable-charge considerations.

2. A. Source of Reimbursement

   Discusses how operating expenses are treated when initially paid by a provider or borne by a provider-based physician. It also addresses how those amounts relate to provider reimbursement and customary charges at a general level.

3. B. Determination of Reasonable Charges

   Addresses reasonable-charge considerations for arrangements established before and after a specific mid-1966 date. It outlines the broad factors used in evaluating physician charges in lease or similar arrangements.

4. 1. Arrangement effected before July 1, 1966

   Covers the treatment of longstanding arrangements that were already in effect before the referenced date. The discussion is limited to general reasonable-charge assessment in that historical context.

5. 2. Arrangements effected after June 30, 1966

   Covers arrangements established after the referenced date and the broader factors considered in evaluating customary and reasonable charges. The section also addresses related considerations involving provider cost experience and comparable settings.

6. a.

   Describes the general bases used to assess customary charges under a lease or similar arrangement. It references prior professional remuneration and operating-cost considerations without disclosing specific decision rules.

7. b.

   Addresses the treatment of disparities between a provider’s receipts and costs in the context of direct billing. The section explains the topic at a high level without disclosing substantive conclusions.

8. c.

   Discusses the role of prevailing charges in nonprovider laboratories when evaluating charges in provider-related arrangements. It emphasizes that comparisons may be limited by the setting and circumstances.