Social Security Act §1833

(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(ii)in the caseof a 1990 conversion factor that is greater than $15.49 but less than$16.51, the conversion factor for a calendar year after 1990 and before1996 shall be the greater of(I)the 1990conversion factor, or(II)the conversionfactor specified in subparagraph (A)(i) for the year involved.(D)Notwithstandingsubparagraph (C), in no case may the conversion factor used to determinepayment for services in a fee schedule area or locality under thissubsection, as adjusted by the adjustment factors specified in subparagraphs[109](A)(iii), exceed the conversion factor used to determinethe amount paid for physicians services that are anesthesiaservices in the area or locality.(5)(A)Payment forthe services of a certified registered nurse anesthetist (for whichpayment may otherwise be made under this part) may be made on thebasis of a claim or request for payment presented by the certifiedregistered nurse anesthetist furnishing such services, or by a hospital,critical access hospital, physician, group practice, or ambulatorysurgical center with which the certified registered nurse anesthetistfurnishing such services has an employment or contractual relationshipthat provides for payment to be made under this part for such servicesto such hospital, critical access hospital, physician, group practice,or ambulatory surgical center.(B)No hospitalor critical access hospital that presents a claim or request for paymentfor services of a certified nurse anesthetist under this part maytreat any uncollected coinsurance amount imposed under this part withrespect to such services as a bad debt of such hospital or criticalaccess hospital for purposes of this title.(6)If an adjustmentunder paragraph (3)(B) results in a reduction in the reasonable chargefor a physicians service and a nonparticipating physician furnishesthe service to an individual entitled to benefits under this partafter the effective date of the reduction, the physicians actualcharge is subject to a limit under section 1842(j)(1)(D).(m)(1)In the case ofphysicians services furnished in a year to an individual, whois covered under the insurance program established by this part andwho incurs expenses for such services, in an area that is designated(under section 332(a)(1)(A) of the Public Health Service Act)[110]as a health professional shortage area as identified by the Secretaryprior to the beginning of such year, in addition to the amount otherwisepaid under this part, there also shall be paid to the physician (orto an employer or facility in the cases described in clause (A) ofsection 1842(b)(6)) (on a monthly or quarterly basis) from the Federal SupplementaryMedical Insurance Trust Fund an amount equal to 10 percent of thepayment amount for the service under this part.(2)For each healthprofessional shortage area identified in paragraph (1) that consistsof an entire county, the Secretary shall provide for the additionalpayment under paragraph (1) without any requirement on the physicianto identify the health professional shortage area involved. The Secretarymay implement the previous sentence using the method specified insubsection (u)(4)(C).(3)The Secretaryshall post on the Internet website of the Centers for Medicare andMedicaid Services a list of the health professional shortage areasidentified in paragraph (1) that consist of a partial county to facilitatethe additional payment under paragraph (1) in such areas.(4)There shall beno administrative or judicial review under section 1869, section 1878, or otherwise,respecting(A)the identificationof a county or area;(B)the assignmentof a specialty of any physician under this paragraph;(C)the assignmentof a physician to a county under this subsection; or(D)the assignmentof a postal ZIP Code to a county or other area under this subsection.(n)(1)(A)The aggregateamount of the payments to be made for all or part of a cost reportingperiod for services described in subsection (a)(2)(E)(i) furnishedunder this part on or after October 1, 1988, and before January 1,1999, and for services described in subsection (a)(2)(E)(ii) furnishedunder this part on or after October 1, 1989, and before January 1,1999, shall be equal to the lesser of(i)the amount determinedwith respect to such services under subsection (a)(2)(B), or(ii)the blend amountfor radiology services and diagnostic procedures determined in accordancewith subparagraph (B).(B)(i)The blend amountfor radiology services and diagnostic procedures for a cost reportingperiod is the sum of(I)the costproportion (as defined in clause (ii)) of the amount described insubparagraph (A)(i); and(II)the chargeproportion (as defined in clause (ii)(II)) of 62 percent (for servicesdescribed in subsection (a)(2)(E)(i)), or (for procedures describedin subsection (a)(2)(E)(ii)), 42 percent or such other percent establishedby the Secretary (or carriers acting pursuant to guidelines issuedby the Secretary) based on prevailing charges established with actualcharge data, of the prevailing charge or (for services described insubsection (a)(2)(E)(i) furnished on or after April 1, 1989 and forservices described in subsection (a)(2)(E)(ii) furnished on or afterJanuary 1, 1992) the fee schedule amount established for participatingphysicians for the same services as if they were furnished in a physiciansoffice in the same locality as determined under section 1842(b) (or, in thecase of services furnished on or after January 1, 1992, under section 1848), less the amounta provider may charge as described in clause (ii) of section 1866(a)(2)(A).(ii)In this subparagraph:(I)The term cost proportion means 50 percent, except that such term means65 percent in the case of outpatient radiology services for portionsof cost reporting periods which occur in fiscal year 1989 and in thecase of diagnostic procedures described in subsection (a)(2)(E)(ii)for portions of cost reporting periods which occur in fiscal year1990, and such term means 42 percent in the case of outpatient radiologyservices for portions of cost reporting periods beginning on or afterJanuary 1, 1991.(II)The term charge proportion means 100 percent minus the cost proportion.(o)(1)In the case ofshoes described in section 1861(s)(12)(A)no paymentmay be made under this part, with respect to any individual for anyyear, for the furnishing of(i)more than onepair of custom molded shoes (including inserts provided with suchshoes) and 2 additional pairs of inserts for such shoes, or(ii)more than onepair of extra-depth shoes (not including inserts provided with suchshoes) and 3 pairs of inserts for such shoes, and(B)with respectto expenses incurred in any calendar year, no more than the amountof payment applicable under paragraph (2) shall be considered as incurredexpenses for purposes of subsections (a) and (b).Payment for shoes (or inserts) under this part shall be consideredto include payment for any expenses for the fitting of such shoes(or inserts).(2)(A)Except asprovided by the Secretary under subparagraphs (B) and (C), the amountof payment under this paragraph for custom molded shoes, extra-depthshoes, and inserts shall be the amount determined for such items bythe Secretary under section 1834(h).(B)The Secretarymay establish payment amounts for shoes and inserts that are lowerthan the amount established under section 1834(h) if the Secretary finds thatshoes and inserts of an appropriate quality are readily availableat or below the amount established under such section.(C)In accordancewith procedures established by the Secretary, an individual entitledto benefits with respect to shoes described in section 1861(s)(12) maysubstitute modification of such shoes instead of obtaining one (ormore, as specified by the Secretary) pair of inserts (other than theoriginal pair of inserts with respect to such shoes). In such case,the Secretary shall substitute, for the payment amount establishedunder section 1834(h), a payment amount that the Secretary estimates will assure thatthere is no net increase in expenditures under this subsection asa result of this subparagraph.(3)In this title,the term shoes includes, except for purposes of subparagraphs(A)(ii) and (B) of paragraph (2), inserts for extra-depth shoes.(p)[Stricken.[111]](q)(1)Each request forpayment, or bill submitted, for an item or service furnished by anentity for which payment may be made under this part and for whichthe entity knows or has reason to believe there has been a referralby a referring physician (within the meaning of section 1877) shall includethe name and unique physician identification number for the referringphysician.(2)(A)In the caseof a request for payment for an item or service furnished by an entityunder this part on an assignment-related basis and for which informationis required to be provided under paragraph (1) but not included, paymentmay be denied under this part.(B)In the caseof a request for payment for an item or service furnished by an entityunder this part not submitted on an assignment-related basis and forwhich information is required to be provided under paragraph (1) butnot included(i)if the entityknowingly and willfully fails to provide such information promptlyupon request of the Secretary or a carrier, the entity may be subjectto a civil money penalty in an amount not to exceed $2,000, and(ii)if the entityknowingly, willfully, and in repeated cases fails, after being notifiedby the Secretary of the obligations and requirements of this subsectionto provide the information required under paragraph (1), the entitymay be subject to exclusion from participation in the programs underthis Act for a period not to exceed 5 years, in accordance with theprocedures of subsections (c), (f), and (g) of section 1128.The provisions of section 1128A (other than subsections (a) and(b)) shall apply to civil money penalties under clause (i) in thesame manner as they apply to a penalty or proceeding under section 1128A(a).(r)(1)With respect toservices described in section 1861(s)(2)(K)(ii) (relating tonurse practitioner or clinical nurse specialist services), paymentmay be made on the basis of a claim or request for payment presentedby the nurse practitioner or clinical nurse specialist furnishingsuch services, or by a hospital, critical access hospital, skillednursing facility or nursing facility (as defined in section 1919(a)), physician,group practice or ambulatory surgical center with which the nursepractitioner or clinical nurse specialist has an employment or contractualrelationship that provides for payment to be made under this partfor such services to such hospital, physician, group practice, orambulatory surgical center.(2)No hospital orcritical access hospital that presents a claim or request for paymentunder this part for services described in section 1861(s)(2)(K)(ii) may treat any uncollected coinsurance amount imposed under thispart with respect to such services as a bad debt of such hospitalfor purposes of this title.(s)The Secretary maynot provide for payment under subsection (a)(1)(A) with respect toan organization unless the organization provides assurances satisfactoryto the Secretary that the organization meets the requirement of section 1866(f) (relatingto maintaining written policies and procedures respecting advancedirectives).(t)[112]Prospective Payment System forHospital Outpatient Department Services.(1)Amountof payment.(A)