(Medicare Claims Processing Manual)

Irrespective of the language in any agreement a provider/supplier has with a third party that is providing financing, that third party cannot purchase the provider/suppliers Medicare receivables.   Subject to the above restrictions on the bank and to the banks meeting the conditions specified in 30.2.4, a bank which is the provider/suppliers billing agent pursuant to an agreement with the provider/supplier and receives and deposits in the provider/suppliers bank account the provider/suppliers Medicare payments may, subject to instructions from the provider/supplier, draw on those funds to pay for its billing services.   Subject to the above restrictions on the bank, the provider/suppliers billing agent, other than the bank, that meets the conditions specified in 30.2.4 and receives and deposits in the provider/suppliers bank account the provider/suppliers Medicare payments may, subject to instructions from the provider/supplier, draw on these funds to pay for its billing services.   Notwithstanding the above restrictions, if a court of competent jurisdiction orders the assignment or reassignment of Medicare payments, Medicare will follow that order if, as stated in 42 C.F.R. 424.73(b)(2) and listed in 42 C.F.R. 424.90, a certified c opy of the court order and of the executed assignment or reassignment (if it was necessary to execute one) is filed with the contractor responsible for processing the claim and the assignment or reassignment (1) applies to all Medicare benefits payable to a particular person or entity during a specified or indefinite time period; or, (2) specifies a particular amount of money, payable to a particular person or entity by the particular contractor.  In all other instances, the Medicare program will make payments subject to the restrictions listed above.  For example, even if a court order directed to a provider/supplier limits the provider/suppliers ability to breach its financial agreement with a third party, the bank is bound by instructions from the provider/supplier.   30.2.6 - Payment to Employer of Physician - Carrier Claims Only  (Rev. 1, 10- 01-03) B3-3060.1  The carrier may pay Part B benefits for covered physician services under an assignment or for enrollees that did not execute assignment before death to the physicians employer, provided that under the terms of the physicians employment, only the employer  and not the physician has the right to charge or collect charges for the physicians services, and certain other conditions and limitations described below are met.  There must be an employer -employee relationship between the physician and the person or organization hiring the physician to perform services, and the terms of the employment must provide that the employer and not the physician has the right to receive the payment for all the latters services within the scope of the employment.  If the employ er has the right, as a condition of employment, to fees for all professional services the physician renders, including those outside the scope of the employment, honor an assignment of benefits to the employer for all such services.   An employer may establish that it qualifies to receive payment for the services of its physicians by submitting the Form CMS -855R.  The employer must provide evidence that the employee is a valid employee by providing the carrier with a Form W- 2 or other acceptable Internal Revenue Service documentation (a pay stub would suffice for new employees who do not yet have a Form W -2.).  30.2.7 - Payment for Services Provided Under a Contractual Arrangement - Carrier Claims Only  (Rev. 472, Issued:  02- 11-05, Effective:  01 -01-05, Implementation:  03- 15-05)  A carrier may make payment to an entity (i.e., a person, group, or facility) enrolled in the Medicare program that submits a claim for services provided by a physician or other person under a contractual arrangement with that entity, regardless of where the service is furnished.  Thus, the service may be furnished on or off the pre mises of the entity submitting the bill and receiving payment.  The entity receiving payment and the physician or other person that furnished the service are both subject to the following program integrity safeguard requirements:   1. The entity receiving payment and the person that furnished the service are jointly and severally responsible for any Medicare overpayment to that entity; and,  2. The person furnishing the service has unrestricted access to claims submitted by an entity for services provided by that person.   30.2.8.2 - University -Affiliated Medical Faculty Practice Plans  - Claims Submitted to Carriers  (Rev. 1, 10- 01-03) B3-3060.3.D   A carrier may make Part B payment to a university -affiliated medical faculty practice plan that has the following attributes:   There is a written agreement between the Governing Board of the University and the Governing Board of the Medical Faculty Practice Plan describing the relationship between both parties.    The Medical Faculty Practice Plan is a 501(c)(3) nonprofit tax- exempt organization, according to IRS regulations.   Physicians of the faculty practice plan are employees of the University and/or medical school.  The plan should furnish a copy of the employment agreement(s) between the faculty physician and the University.   Physicians are full or part -time faculty members of the Universitys School of Medicine, licensed to practice medicine in the State.    The faculty practice plan may only be affiliated with one University, and this relationship is described in the written agreement between the University and the Medical Faculty Practice Plan.    Members of the faculty practice plan are represented on the Governing Board of the practice plan.  The Board has the authority to make or delegate management and operational decisions on behalf of the physicians participating in the practice plan.   Faculty practice plan physicians have unrestricted access to the billing records, medical documentation, and claims forms for services submitted on their behalf by the practice plan. The faculty practice plan provides documentation establishing the existen ce of this policy.   The physicians abide by the rules and regulations of the Medical Faculty Practice Plan.    The faculty practice plan is accountable to Medicare for any claims that are submitted on behalf of the plans physicians for services provided to Medicare beneficiaries.  Thus, the plan is responsible for refunding any overpayments to Medicare that are co llected on behalf of the plans physicians.  Both the Medical Faculty Practice Plan and the plans physicians must enroll in the Medicare program by completing the Form CMS -855B and Form CMS -855R (Medicare health care provider/supplier enrollment application forms).  Instructions for processing Form CMS -855B are referenced in Program Integrity Manual.  For those entities that are part of the organizational structure of the University, see 30.2.12, on payment to special accounts.  These entities may include departments, specialties, practice plans, or similar subdivisions of a university or medical school.  30.2.8.3 - Indirect Payment Procedure (IPP) -  Payment to Entities that Provide Coverage Complementary to Medicare Part B  (Rev. 2896, Issued: 03- 07-14, Effective: 06 -06-14, Implementation: 06- 06-14)  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 15.7.9.7 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 beneficiarys 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 Medic are 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 beneficiarys 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 beneficiarys 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 beneficiarys specific service.  Therefore, claims for services that have alre ady been billed to Medicare shall be denied (with appeal rights) by Medicares 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 beneficiarys service is payable under Part C and a Medicare Advantage organization i s 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 beneficiarys service.  In these types of dual or multiple enrollment situations, services that are p ayable 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 Medicares 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 entitys continued compliance with the regulatory requirements described in 42 C.F.R. 424.66.  30.2.9 Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti -Markup Payment Limitation - Claims Submitted to A/B MACs (Part B)  (Rev.  4473, Issued: 12-6- 19; Effective: 3 -9-20; Implementation: 3 -9-20)  A physician or other supplier may bill for the technical component and/or professional component of a diagnostic test that was ordered by the physician or other supplier (or ordered by a party related to the billing physician or other supplier through common ownership or control), subject to an anti -markup payment limitation, if the diagnostic test is performed by a physician who does not share a practice with the billing physician or other supplier.  (This claim and payment limitation does not apply to clinical diagnostic laboratory tests, which are paid under the Clinical Laboratory Fee Schedule.)  Under the anti-markup payment limitation, payment to the billing physician or other supplier (less the deductibles and coinsurance paid by the beneficiary or on behalf of the beneficiary) for the t echnical component or professional component of the diagnostic test may not exceed the lowest of the following amounts:  (1) The performing physician/suppliers net charge to the billing physician or other supplier.* (With respect to the technical component, the performing supplier is the physician who supervised the test, and with respect to the professional component, the performing supplier is the physician who performed the professional component;  (2) The billing physician or other suppliers actual charge; and  (3) The fee schedule amount for the test that would be allowed if the performing physician or other supplier billed directly.  (See section 10.1.1.2 for information on payment jurisdiction for services subject to the anti- markup payment limitation.)   * The net charge must be determined without regard to any charge that is intended to reflect the cost of equipment or space leased to the performing supplier by or through the billing physician or other supplier.  Exception to the Anti -markup Payment Limitation