Social Security Act §1833

(i)The blend amountfor a cost reporting period is the sum of(I)the costproportion (as defined in clause (ii)(I)) of the amount describedin subparagraph (A)(i), and(II)the ASCproportion (as defined in clause (ii)(II)) of the standard overheadamount payable with respect to the same surgical procedure as if itwere provided in an ambulatory surgical center in the same area, asdetermined under paragraph (2)(A), less the amount a provider maycharge as described in clause (ii) of section 1866(a)(2)(A).(ii)Subject toparagraph (4), in this paragraph:(I)The term cost proportion means 75 percent for cost reporting periodsbeginning in fiscal year 1988, 50 percent for portions of cost reportingperiods beginning on or after October 1, 1988, and ending on or beforeDecember 31, 1990, and 42 percent for portions of cost reporting periodsbeginning on or after January 1, 1991.(II)The term ASC proportion means 25 percent for cost reporting periodsbeginning in fiscal year 1988, 50 percent for portions of cost reportingperiods beginning on or after October 1, 1988, and ending on or beforeDecember 31, 1990, and 58 percent for portions of cost reporting periodsbeginning on or after January 1, 1991.(4)(A)In the caseof a hospital that(i)makes applicationto the Secretary and demonstrates that it specializes in eye servicesor eye and ear services (as determined by the Secretary),(ii)receives morethan 30 percent of its total revenues from outpatient services, and(iii)on October1, 1987(I)was aneye specialty hospital or an eye and ear specialty hospital, or(II)wasoperated as an eye or eye and ear unit (as defined in subparagraph(B)) of a general acute care hospital which, on the date of the applicationdescribed in clause (i), operates less than 20 percent of the bedsthat the hospital operated on October 1, 1987, and has sold or otherwisedisposed of a substantial portion of the hospitals other acutecare operations,the cost proportion and ASC proportion in effect under subclauses(I) and (II) of paragraph (3)(B)(ii) for cost reporting periods beginningin fiscal year 1988 shall remain in effect for cost reporting periodsbeginning on or after October 1, 1988, and before January 1, 1995.(B)For purposesof this subparagraph (A)(iii)(II), the term eye or eye andear unit means a physically separate or distinct unit containingseparate surgical suites devoted solely to eye or eye and ear services.(5)(A)The Secretaryis authorized to provide by regulations that in the case of a surgicalprocedure, specified by the Secretary pursuant to paragraph (1)(A),performed in an ambulatory surgical center described in such paragraph,there shall be paid (in lieu of any amounts otherwise payable underthis part) with respect to the facility services furnished by suchcenter and with respect to all related services (including physiciansservices, laboratory, X-ray, and diagnostic services) a single all-inclusivefee established pursuant to subparagraph (B), if all parties furnishingall such services agree to accept such fee (to be divided among theparties involved in such manner as they shall have previously agreedupon) as full payment for the services furnished.(B)In implementingthis paragraph, the Secretary shall establish with respect to eachsurgical procedure specified pursuant to paragraph (1)(A) the amountof the all-inclusive fee for such procedure, taking into account suchfactors as may be appropriate. The amount so established with respectto any surgical procedure shall be reviewed periodically and may beadjusted by the Secretary, when appropriate, to take account of varyingconditions in different areas.(6)Any person, includinga facility having an agreement under section 1832(a)(2)(F)(i), who knowinglyand willfully presents, or causes to be presented, a bill or requestfor payment, for an intraocular lens inserted during or subsequentto cataract surgery for which payment may be made under paragraph(2)(A)(iii), is subject to a civil money penalty of not to exceed$2,000. The provisions of section 1128A (other than subsections (a) and(b)) shall apply to a civil money penalty under the previous sentencein the same manner as such provisions apply to a penalty or proceedingunder section 1128A(a).(7)(A)For purposesof paragraph (2)(D)(iv), the Secretary may provide, in the case ofan ambulatory surgical center that does not submit, to the Secretaryin accordance with this paragraph, data required to be submitted onmeasures selected under this paragraph with respect to a year, anyannual increase provided under the system established under paragraph(2)(D) for such year shall be reduced by 2.0 percentage points. Areduction under this subparagraph shall apply only with respect tothe year involved and the Secretary shall not take into account suchreduction in computing any annual increase factor for a subsequentyear.(B)Except asthe Secretary may otherwise provide, the provisions of subparagraphs(B), (C), (D), and (E) of paragraph (17) of section 1833(t) shall applywith respect to services of ambulatory surgical centers under thisparagraph in a similar manner to the manner in which they apply undersuch paragraph and, for purposes of this subparagraph, any referenceto a hospital, outpatient setting, or outpatient hospital servicesis deemed a reference to an ambulatory surgical center, the settingof such a center, or services of such a center, respectively.(8)[105]The Secretary shall conduct a similar type of reviewas required under paragraph (22) ofsection 1833(t)), including the second sentence of subparagraph(C) of such paragraph, to payment for services under this subsection,and make such revisions under this paragraph, in an appropriate manner(as determined by the Secretary).(j)Whenever a finaldetermination is made that the amount of payment made under this parteither to a provider of services or to another person pursuant toan assignment under section 1842(b)(3)(B)(ii) was in excessof or less than the amount of payment that is due, and payment ofsuch excess or deficit is not made (or effected by offset) within30 days of the date of the determination, interest shall accrue onthe balance of such excess or deficit not paid or offset (to the extentthat the balance is owed by or owing to the provider) at a rate determinedin accordance with the regulations of the Secretary of the Treasuryapplicable to charges for late payments.(k)With respect toservices described in section 1861(s)(10)(B), the Secretary mayprovide, instead of the amount of payment otherwise provided underthis part, for payment of such an amount or amounts as reasonablyreflects the general cost of efficiently providing such services.(l)(1)(A)The Secretaryshall establish a fee schedule for services of certified registerednurse anesthetists under section 1861(s)(11).(B)In establishingthe fee schedule under this paragraph the Secretary may utilize asystem of time units, a system of base and time units, or any appropriatemethodology.(C)The provisionsof this subsection shall not apply to certain services furnished incertain hospitals in rural areas under the provisions of section 9320(k)of the Omnibus Budget Reconciliation Act of 1986[106], asamended by section 6132 of the Omnibus Budget Reconciliation Act of1989[107].(2)Except as providedin paragraph (3), the fee schedule established under paragraph (1)shall be initially based on audited data from cost reporting periodsending in fiscal year 1985 and such other data as the Secretary determinesnecessary.(3)(A)In establishingthe initial fee schedule for those services, the Secretary shall adjustthe fee schedule to the extent necessary to ensure that the estimatedtotal amount which will be paid under this title for those servicesplus applicable coinsurance in 1989 will equal the estimated totalamount which would be paid under this title for those services in1989 if the services were included as inpatient hospital servicesand payment for such services was made under part A in the same manneras payment was made in fiscal year 1987, adjusted to take into accountchanges in prices and technology relating to the administration ofanesthesia.(B)The Secretaryshall also reduce the prevailing charge of physicians for medicaldirection of a certified registered nurse anesthetist, or the feeschedule for services of certified registered nurse anesthetists,or both, to the extent necessary to ensure that the estimated totalamount which will be paid under this title plus applicable coinsurancefor such medical direction and such services in 1989 and 1990 willnot exceed the estimated total amount which would have been paid plusapplicable coinsurance but for the enactment of the amendments madeby section 9320 of the Omnibus Budget Reconciliation Act of 1986[108]. A reduced prevailing charge under this subparagraph shall becomethe prevailing charge but for subsequent years for purposes of applyingthe economic index under the fourth sentence of section 1842(b)(3).(4)(A)Except asprovided in subparagraphs (C) and (D), in determining the amount paidunder the fee schedule under this subsection for services furnishedon or after January 1, 1991, by a certified registered nurse anesthetistwho is not medically directed(i)the conversionfactor shall be(I)for servicesfurnished in 1991, $15.50,(II)for servicesfurnished in 1992, $15.75,(III)forservices furnished in 1993, $16.00,(IV)for servicesfurnished in 1994, $16.25,(V)for servicesfurnished in 1995, $16.50,(VI)for servicesfurnished in 1996, $16.75, and(VII)forservices furnished in calendar years after 1996, the previous yearsconversion factor increased by the update determined under section 1848(d) for physiciananesthesia services for that year;(ii)the paymentareas to be used shall be the fee schedule areas used under section 1848 (or, in the caseof services furnished during 1991, the localities used under section 1842(b)) for purposesof computing payments for physicians services that are anesthesiaservices;(iii)the geographicadjustment factors to be applied to the conversion factor under clause(i) for services in a fee schedule area or locality is(I)in thecase of services furnished in 1991, the geographic work index valueand the geographic practice cost index value specified in section 1842(q)(1)(B) forphysicians services that are anesthesia services furnishedin the area or locality, and(II)in thecase of services furnished after 1991, the geographic work index value,the geographic practice cost index value, and the geographic malpracticeindex value used for determining payments for physicians servicesthat are anesthesia services under section 1848,with 70 percent of the conversion factor treated as attributableto work and 30 percent as attributable to overhead for services furnishedin 1991 (and the portions attributable to work, practice expenses,and malpractice expenses in 1992 and thereafter being the same asis applied under section 1848).(B)(i)Except as providedin clause (ii) and subparagraph (D), in determining the amount paidunder the fee schedule under this subsection for services furnishedon or after January 1, 1991, and before January 1, 1994, by a certifiedregistered nurse anesthetist who is medically directed, the Secretaryshall apply the same methodology specified in subparagraph (A).(ii)The conversionfactor used under clause (i) shall be(I)for servicesfurnished in 1991, $10.50,(II)for servicesfurnished in 1992, $10.75, and(III)forservices furnished in 1993, $11.00.(iii)In the caseof services of a certified registered nurse anesthetist who is medicallydirected or medically supervised by a physician which are furnishedon or after January 1, 1994, the fee schedule amount shall be one-halfof the amount described in section 1848(a)(5)(B) with respect to thephysician.(C)Notwithstandingsubclauses (I) through (V) of subparagraph (A)(i)(i)in the case ofa 1990 conversion factor that is greater than $16.50, the conversionfactor for a calendar year after 1990 and before 1996 shall be the1990 conversion factor reduced by the product of the last digit ofthe calendar year and one-fifth of the amount by which the 1990 conversionfactor exceeds $16.50; and