evekhm/cms_iom_500 huggingface dataset:
Social Security Act §1833
(i)(1)The Secretaryshall, in consultation with appropriate medical organizations(A)specify thosesurgical procedures which are appropriately (when considered in termsof the proper utilization of hospital inpatient facilities) performedon an inpatient basis in a hospital but which also can be performedsafely on an ambulatory basis in an ambulatory surgical center (meetingthe standards specified under section 1832(a)(2)(F)(i)), critical accesshospital, or hospital outpatient department, and(B)specify thosesurgical procedures which are appropriately (when considered in termsof the proper utilization of hospital inpatient facilities) performedon an inpatient basis in a hospital but which also can be performedsafely on an ambulatory basis in a physicians office.The lists of procedures established under subparagraphs (A)and (B) shall be reviewed and updated not less often than every 2years.(2)(A)For servicesfurnished prior to the implementation of the system described in subparagraph(D), subject to subparagraph (E), the amount of payment to be madefor facility services furnished in connection with a surgical procedurespecified pursuant to paragraph (1)(A) and furnished to an individualin an ambulatory surgical center described in such paragraph shallbe equal to 80 percent of a standard overhead amount established bythe Secretary (with respect to each such procedure) on the basis ofthe Secretarys estimate of a fair fee which(i)takes into accountthe costs incurred by such centers, or classes of centers, generallyin providing services furnished in connection with the performanceof such procedure as determined in accordance with a survey (basedupon a representative sample of procedures and facilities) of theactual audited costs incurred by such centers in providing such services,(ii)takes suchcosts into account in such a manner as will assure that the performanceof the procedure in such a center will result in substantially lessamounts paid under this title than would have been paid if the procedurehad been performed on an inpatient basis in a hospital, and(iii)in the caseof insertion of an intraocular lens during or subsequent to cataractsurgery includes payment which is reasonable and related to the costof acquiring the class of lens involved.Each amount so established shall be reviewed and updated notlater than July 1, 1987, and annually thereafter to take account ofvarying conditions in different areas.
Social Security Act §1833
Each amount so established shall be reviewed and updated notlater than July 1, 1987, and annually thereafter to take account ofvarying conditions in different areas.(B)The amountof payment to be made under this part for facility services furnished,in connection with a surgical procedure specified pursuant to paragraph(1)(B), in a physicians office shall be equal to 80 percentof a standard overhead amount established by the Secretary (with respectto each such procedure) on the basis of the Secretarys estimateof a fair fee which(i)takes into accountadditional costs, not usually included in the professional fee, incurredby physicians in securing, maintaining, and staffing the facilitiesand ancillary services appropriate for the performance of such procedurein the physicians office, and(ii)takes suchitems into account in such a manner which will assure that the performanceof such procedure in the physicians office will result in substantiallyless amounts paid under this title than would have been paid if theservices had been furnished on an inpatient basis in a hospital.Each amount so established shall be reviewed and updated notlater than July 1, 1987, and annually thereafter and may be adjustedby the Secretary, when appropriate, to take account of varying conditionsin different areas.(C)(i)Notwithstandingthe second sentence of each of subparagraphs (A) and (B), except asotherwise specified in clauses (ii), (iii), and (iv), if the Secretaryhas not updated amounts established under such subparagraphs or undersubparagraph (D), with respect to facility services furnished duringa fiscal year (beginning with fiscal year 1986 or a calendar year(beginning with 2006)), such amounts shall be increased by the percentageincrease in the Consumer Price Index for all urban consumers (U.S.city average) as estimated by the Secretary for the 12-month periodending with the midpoint of the year involved.(ii)In each ofthe fiscal years 1998 through 2002, the increase under this subparagraphshall be reduced (but not below zero) by 2.0 percentage points.(iii)In fiscalyear 2004, beginning with April 1, 2004, the increase under this subparagraphshall be the Consumer Price Index for all urban consumers (U.S. cityaverage) as estimated by the Secretary for the 12-month period endingwith March 31, 2003, minus 3.0 percentage points.
Social Security Act §1833
(iv)In fiscal year2005, the last quarter of calendar year 2005, and each of calendaryears 2006 through 2009, the increase under this subparagraph shallbe 0 percent.(D)(i)Taking into accountthe recommendations in the report under section 626(d) of MedicarePrescription Drug, Improvement, and Modernization Act of 2003, theSecretary shall implement a revised payment system for payment ofsurgical services furnished in ambulatory surgical centers.(ii)In the yearthe system described in clause (i) is implemented, such system shallbe designed to result in the same aggregate amount of expendituresfor such services as would be made if this subparagraph did not apply,as estimated by the Secretary and taking into account reduced expendituresthat would apply if subparagraph (E) were to continue to apply, asestimated by the Secretary.(iii)The Secretaryshall implement the system described in clause (i) for periods ina manner so that it is first effective beginning on or after January1, 2006, and not later than January 1, 2008.(iv)The Secretarymay implement such system in a manner so as to provide for a reductionin any annual update for failure to report on quality measures inaccordance with paragraph (7).(v)In implementingthe system described in clause (i) for 2011 and each subsequent year,any annual update under such system for the year, after applicationof clause (iv), shall be reduced by the productivity adjustment describedin section 1886(b)(3)(B)(xi)(II). The application of the preceding sentence may result in such updatebeing less than 0.0 for a year, and may result in payment rates underthe system described in clause (i) for a year being less than suchpayment rates for the preceding year.(vi)There shallbe no administrative or judicial review under section 1869, 1878, or otherwise, of the classification system, the relative weights,payment amounts, and the geographic adjustment factor, if any, underthis subparagraph.(E)With respectto surgical procedures furnished on or after January 1, 2007, andbefore the effective date of the implementation of a revised paymentsystem under subparagraph (D), if(i)the standardoverhead amount under subparagraph (A) for a facility service forsuch procedure, without the application of any geographic adjustment,exceeds
Social Security Act §1833
(i)the standardoverhead amount under subparagraph (A) for a facility service forsuch procedure, without the application of any geographic adjustment,exceeds(ii)the MedicareOPD fee schedule amount established under the prospective paymentsystem for hospital outpatient department services under paragraph(3)(D) of section 1833(t) for such service for such year, determined without regard to geographicadjustment under paragraph (2)(D) of such section,the Secretary shall substitute under subparagraph (A) the amountdescribed in clause (ii) for the standard overhead amount for suchservice referred to in clause (i).(iii)The Secretaryshall implement the system described in clause (i) for periods ina manner so that it is first effective beginning on or after January1, 2006, and not later than January 1, 2008.(iv)The Secretarymay implement such system in a manner so as to provide for a reductionin any annual update for failure to report on quality measures inaccordance with paragraph (7).(v)There shall beno administrative or judicial review under section 1869, 1878, or otherwise, of the classificationsystem, the relative weights, payment amounts, and the geographicadjustment factor, if any, under this subparagraph.(3)(A)The aggregateamount of the payments to be made under this part for outpatient hospitalfacility services or critical access hospital services furnished beforeJanuary 1, 1999, in connection with surgical procedures specifiedunder paragraph (1)(A) shall be equal to the lesser of(i)the amount determinedwith respect to such services under subsection (a)(2)(B); or(ii)the blend amount(described in subparagraph (B)).(B)
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,
Social Security Act §1833
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.
Social Security Act §1833
(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).
Social Security Act §1833
(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.
Social Security Act §1833
(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
Social Security Act §1833
(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.
Social Security Act §1833
(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.
Social Security Act §1833
(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.