42 USC § 1395g - Payments to providers of services
(a)
Determination of amount
The Secretary shall periodically determine the amount which should be paid under this part to each provider of services with respect to the services furnished by it, and the provider of services shall be paid, at such time or times as the Secretary believes appropriate (but not less often than monthly) and prior to audit or settlement by the Government Accountability Office, from the Federal Hospital Insurance Trust Fund, the amounts so determined, with necessary adjustments on account of previously made overpayments or underpayments; except that no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period.
(b)
Conditions
No payment shall be made to a provider of services which is a hospital for or with respect to services furnished by it for any period with respect to which it is deemed, under section
1395x
(w)(2) of this title, to have in effect an arrangement with a quality improvement organization for the conduct of utilization review activities by such organization unless such hospital has paid to such organization the amount due (as determined pursuant to such section) to such organization for the review activities conducted by it pursuant to such arrangements or such hospital has provided assurances satisfactory to the Secretary that such organization will promptly be paid the amount so due to it from the proceeds of the payment claimed by the hospital. Payment under this subchapter for utilization review activities provided by a quality improvement organization pursuant to an arrangement or deemed arrangement with a hospital under section
1395x
(w)(2) of this title shall be calculated without any requirement that the reasonable cost of such activities be apportioned among the patients of such hospital, if any, to whom such activities were not applicable.
(c)
Payments under assignment or power of attorney
No payment which may be made to a provider of services under this subchapter for any service furnished to an individual shall be made to any other person under an assignment or power of attorney; but nothing in this subsection shall be construed
(1)
to prevent the making of such a payment in accordance with an assignment from the provider if such assignment is made to a governmental agency or entity or is established by or pursuant to the order of a court of competent jurisdiction, or
(2)
to preclude an agent of the provider of services from receiving any such payment if (but only if) such agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for his services for or in connection with the billing or collection of payments due such provider under this subchapter is unrelated (directly or indirectly) to the amount of such payments or the billings therefor, and is not dependent upon the actual collection of any such payment.
(d)
Accrual of interest on balance of excess or deficit not paid
Whenever a final determination is made that the amount of payment made under this part to a provider of services was in excess of or less than the amount of payment that is due, and payment of such excess or deficit is not made (or effected by offset) within 30 days of the date of the determination, interest shall accrue on the balance of such excess or deficit not paid or offset (to the extent that the balance is owed by or owing to the provider) at a rate determined in accordance with the regulations of the Secretary of the Treasury applicable to charges for late payments.
(e)
Periodic interim payments
(1)
The Secretary shall provide payment under this part for inpatient hospital services furnished by a subsection (d) hospital (as defined in section
1395ww
(d)(1)(B) of this title, and including a distinct psychiatric or rehabilitation unit of such a hospital) and a subsection (d) Puerto Rico hospital (as defined in section
1395ww
(d)(9)(A) of this title) on a periodic interim payment basis (rather than on the basis of bills actually submitted) in the following cases:
(A)
Upon the request of a hospital which is paid through an agency or organization with an agreement with the Secretary under section
1395h of this title, if the agency or organization, for three consecutive calendar months, fails to meet the requirements of subsection (c)(2) of such section and if the hospital meets the requirements (in effect as of October 1, 1986) applicable to payment on such a basis, until such time as the agency or organization meets such requirements for three consecutive calendar months.
(B)
In the case of a hospital that—
(i)
has a disproportionate share adjustment percentage (as established in clause (iv) of such section) of at least 5.1 percent (as computed for purposes of establishing the average standardized amounts for discharges occurring during fiscal year 1987), and
but only if the hospital was being paid for inpatient hospital services on such a periodic interim payment basis as of June 30, 1987, and continues to meet the requirements (in effect as of October 1, 1986) applicable to payment on such a basis.
(2)
The Secretary shall provide (or continue to provide) for payment on a periodic interim payment basis (under the standards established under section
405.454(j) of title
42, Code of Federal Regulations, as in effect on October 1, 1986, in the cases described in subparagraphs (A) through (D)) with respect to—
(A)
inpatient hospital services of a hospital that is not a subsection (d) hospital (as defined in section
1395ww
(d)(1)(B) of this title);
(B)
a hospital which is receiving payment under a State hospital reimbursement system under section
1395f
(b)(3) or
1395ww
(c) of this title, if payment on a periodic interim payment basis is an integral part of such reimbursement system;
if the provider of such services elects to receive, and qualifies for, such payments.
(3)
In the case of a subsection (d) hospital or a subsection (d) Puerto Rico hospital (as defined for purposes of section
1395ww of this title) which has significant cash flow problems resulting from operations of its intermediary or from unusual circumstances of the hospital’s operation, the Secretary may make available appropriate accelerated payments.
(4)
A hospital created by the merger or consolidation of 2 or more hospitals or hospital campuses shall be eligible to receive periodic interim payment on the basis described in paragraph (1)(B) if—
(a)
Determination of amount
The Secretary shall periodically determine the amount which should be paid under this part to each provider of services with respect to the services furnished by it, and the provider of services shall be paid, at such time or times as the Secretary believes appropriate (but not less often than monthly) and prior to audit or settlement by the Government Accountability Office, from the Federal Hospital Insurance Trust Fund, the amounts so determined, with necessary adjustments on account of previously made overpayments or underpayments; except that no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period.
(b)
Conditions
No payment shall be made to a provider of services which is a hospital for or with respect to services furnished by it for any period with respect to which it is deemed, under section
1395x
(w)(2) of this title, to have in effect an arrangement with a quality improvement organization for the conduct of utilization review activities by such organization unless such hospital has paid to such organization the amount due (as determined pursuant to such section) to such organization for the review activities conducted by it pursuant to such arrangements or such hospital has provided assurances satisfactory to the Secretary that such organization will promptly be paid the amount so due to it from the proceeds of the payment claimed by the hospital. Payment under this subchapter for utilization review activities provided by a quality improvement organization pursuant to an arrangement or deemed arrangement with a hospital under section
1395x
(w)(2) of this title shall be calculated without any requirement that the reasonable cost of such activities be apportioned among the patients of such hospital, if any, to whom such activities were not applicable.
(c)
Payments under assignment or power of attorney
No payment which may be made to a provider of services under this subchapter for any service furnished to an individual shall be made to any other person under an assignment or power of attorney; but nothing in this subsection shall be construed
(1)
to prevent the making of such a payment in accordance with an assignment from the provider if such assignment is made to a governmental agency or entity or is established by or pursuant to the order of a court of competent jurisdiction, or
(2)
to preclude an agent of the provider of services from receiving any such payment if (but only if) such agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for his services for or in connection with the billing or collection of payments due such provider under this subchapter is unrelated (directly or indirectly) to the amount of such payments or the billings therefor, and is not dependent upon the actual collection of any such payment.
(d)
Accrual of interest on balance of excess or deficit not paid
Whenever a final determination is made that the amount of payment made under this part to a provider of services was in excess of or less than the amount of payment that is due, and payment of such excess or deficit is not made (or effected by offset) within 30 days of the date of the determination, interest shall accrue on the balance of such excess or deficit not paid or offset (to the extent that the balance is owed by or owing to the provider) at a rate determined in accordance with the regulations of the Secretary of the Treasury applicable to charges for late payments.
(e)
Periodic interim payments
(1)
The Secretary shall provide payment under this part for inpatient hospital services furnished by a subsection (d) hospital (as defined in section
1395ww
(d)(1)(B) of this title, and including a distinct psychiatric or rehabilitation unit of such a hospital) and a subsection (d) Puerto Rico hospital (as defined in section
1395ww
(d)(9)(A) of this title) on a periodic interim payment basis (rather than on the basis of bills actually submitted) in the following cases:
(A)
Upon the request of a hospital which is paid through an agency or organization with an agreement with the Secretary under section
1395h of this title, if the agency or organization, for three consecutive calendar months, fails to meet the requirements of subsection (c)(2) of such section and if the hospital meets the requirements (in effect as of October 1, 1986) applicable to payment on such a basis, until such time as the agency or organization meets such requirements for three consecutive calendar months.
(B)
In the case of a hospital that—
(i)
has a disproportionate share adjustment percentage (as established in clause (iv) of such section) of at least 5.1 percent (as computed for purposes of establishing the average standardized amounts for discharges occurring during fiscal year 1987), and
but only if the hospital was being paid for inpatient hospital services on such a periodic interim payment basis as of June 30, 1987, and continues to meet the requirements (in effect as of October 1, 1986) applicable to payment on such a basis.
(2)
The Secretary shall provide (or continue to provide) for payment on a periodic interim payment basis (under the standards established under section
405.454(j) of title
42, Code of Federal Regulations, as in effect on October 1, 1986, in the cases described in subparagraphs (A) through (D)) with respect to—
(A)
inpatient hospital services of a hospital that is not a subsection (d) hospital (as defined in section
1395ww
(d)(1)(B) of this title);
(B)
a hospital which is receiving payment under a State hospital reimbursement system under section
1395f
(b)(3) or
1395ww
(c) of this title, if payment on a periodic interim payment basis is an integral part of such reimbursement system;
if the provider of such services elects to receive, and qualifies for, such payments.
(3)
In the case of a subsection (d) hospital or a subsection (d) Puerto Rico hospital (as defined for purposes of section
1395ww of this title) which has significant cash flow problems resulting from operations of its intermediary or from unusual circumstances of the hospital’s operation, the Secretary may make available appropriate accelerated payments.
(4)
A hospital created by the merger or consolidation of 2 or more hospitals or hospital campuses shall be eligible to receive periodic interim payment on the basis described in paragraph (1)(B) if—
Source
(Aug. 14, 1935, ch. 531, title XVIII, § 1815, as added Pub. L. 89–97, title I, § 102(a),July 30, 1965, 79 Stat. 297; amended Pub. L. 94–182, title I, § 112(a)(2),Dec. 31, 1975, 89 Stat. 1055; Pub. L. 95–142, § 2(a)(2),Oct. 25, 1977, 91 Stat. 1175; Pub. L. 96–473, § 6(i),Oct. 19, 1980, 94 Stat. 2266; Pub. L. 97–248, title I, §§ 117(a)(1),
148
(b),Sept. 3, 1982, 96 Stat. 354, 394; Pub. L. 99–509, title IX, § 9311(a)(1),Oct. 21, 1986, 100 Stat. 1996; Pub. L. 101–239, title VI, § 6021(a),Dec. 19, 1989, 103 Stat. 2166; Pub. L. 105–33, title IV, § 4603(b),Aug. 5, 1997, 111 Stat. 470; Pub. L. 108–173, title IV, § 405(c)(1), title VII, § 736(a)(3),Dec. 8, 2003, 117 Stat. 2266, 2354; Pub. L. 108–271, § 8(b),July 7, 2004, 118 Stat. 814; Pub. L. 112–40, title II, § 261(a)(3)(B),Oct. 21, 2011, 125 Stat. 423.)
Amendments
2011—Subsec. (b). Pub. L. 112–40substituted “quality improvement” for “quality control and peer review” in two places.
2004—Subsec. (a). Pub. L. 108–271substituted “Government Accountability Office” for “General Accounting Office”.
2003—Subsec. (e)(1)(B). Pub. L. 108–173, § 736(a)(3), substituted “of a hospital” for “of hospital” in introductory provisions.
Subsec. (e)(2). Pub. L. 108–173, § 405(c)(1)(A), inserted “, in the cases described in subparagraphs (A) through (D)” after “1986” in introductory provisions.
Subsec. (e)(2)(E). Pub. L. 108–173, § 405(c)(1)(B)–(D), added subpar. (E).
1997—Subsec. (e)(2)(C) to (E). Pub. L. 105–33inserted “and” at end of subpar. (C), redesignated subpar. (E) as (D), and struck out former subpar. (D) which read as follows: “home health services; and”.
1989—Subsec. (e)(4). Pub. L. 101–239added par. (4).
1986—Subsec. (e). Pub. L. 99–509added subsec. (e).
1982—Subsec. (b). Pub. L. 97–248, § 148(b), substituted “quality control and peer review organization” for “Professional Standards Review Organization” wherever appearing.
Subsec. (d). Pub. L. 97–248, § 117(a)(1), added subsec. (d).
1980—Subsec. (c). Pub. L. 96–473substituted “for or in connection with” for “for on in connection with”.
1977—Subsec. (c). Pub. L. 95–142added subsec. (c).
1975—Pub. L. 94–182designated existing provisions as subsec. (a) and added subsec. (b).
Effective Date of 2011 Amendment
Amendment by Pub. L. 112–40applicable to contracts entered into or renewed on or after Jan. 1, 2012, see section 261(e) ofPub. L. 112–40, set out as a note under section
1320c of this title.
Effective Date of 2003 Amendment
Pub. L. 108–173, title IV, § 405(c)(3),Dec. 8, 2003, 117 Stat. 2267, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to payments made on or after July 1, 2004.”
Effective Date of 1997 Amendment
Amendment by Pub. L. 105–33applicable to cost reporting periods beginning on or after Oct. 1, 1999, except as otherwise provided, see section 4603(d) ofPub. L. 105–33, set out as an Effective Date note under section
1395fff of this title.
Effective Date of 1989 Amendment
Section 6021(b) ofPub. L. 101–239provided that: “The amendment made by subsection (a) [amending this section] shall apply to payments made for discharges occurring on or after the expiration of the 30-day period that begins on the date of the enactment of this Act [Dec. 19, 1989], regardless of the date of the merger or consolidation involved.”
Effective Date of 1986 Amendment
Section 9311(a)(2) ofPub. L. 99–509provided that: “The amendment made by paragraph (1) [amending this section] shall apply to claims received on or after July 1, 1987.”
Effective Date of 1982 Amendment
Section 117(b) ofPub. L. 97–248provided that: “The amendments made by subsection (a) [amending this section and section
1395l of this title] apply to final determinations made on or after the date of the enactment of this Act [Sept. 3, 1982].”
Amendment by section 148(b) ofPub. L. 97–248effective with respect to contracts entered into or renewed on or after Sept. 3, 1982, see section 149 ofPub. L. 97–248, set out as an Effective Date note under section
1320c of this title.
Effective Date of 1977 Amendment
Section 2(a)(4) ofPub. L. 95–142provided that: “The amendments made by this subsection [amending this section and sections
1395u and
1396a of this title] shall apply with respect to care and services furnished on or after the date of the enactment of this Act [Oct. 25, 1977].”
Effective Date of 1975 Amendment
Amendment by Pub. L. 94–182effective with respect to utilization review activities conducted on and after the first day of the first month which begins more than 30 days after Dec. 31, 1975, see section 112(d) ofPub. L. 94–182, set out as a note under section
1395x of this title.
Development of Alternative Timing Methods of Periodic Interim Payments
Pub. L. 108–173, title IV, § 405(c)(2),Dec. 8, 2003, 117 Stat. 2267, provided that: “With respect to periodic interim payments to critical access hospitals for inpatient critical access hospital services under section 1815(e)(2)(E) of the Social Security Act [subsec. (e)(2)(E) of this section], as added by paragraph (1), the Secretary [of Health and Human Services] shall develop alternative methods for the timing of such payments.”
Transition
Section 9311(a)(3) ofPub. L. 99–509provided that: “Upon the request of a hospital which—
“(A) as of June 30, 1987, is receiving payments under part A of title XVIII of such Act [this part] for inpatient hospital services on a periodic interim payment basis,
“(B) requests continuation of payment on such basis, and
“(C) is paid through an agency or organization with an agreement under section 1816 of such Act [section
1395h of this title],
the Secretary of Health and Human Services shall continue payment on such a basis until not earlier than the end of the first period of three consecutive calendar months (beginning no earlier than April 1987) during all of which the agency or organization has met the requirements of section 1816(c)(2) of such Act (relating to prompt payment of claims).”
Delay in Periodic Interim Payments
Section 120 ofPub. L. 97–248provided that: “Notwithstanding section 1815(a) of the Social Security Act [subsec. (a) of this section], in the case of a hospital which is paid periodic interim payments under such section, the Secretary of Health and Human Services shall provide that—
“(1) with respect to the last 21 days for which such payments would otherwise be made during fiscal year 1983, such payments shall be deferred until fiscal year 1984; and
“(2) with respect to the last 21 days for which such payments would otherwise be made during fiscal year 1984, such payments shall be deferred until fiscal year 1985.”
Pub. L. 96–499, title IX, § 959,Dec. 5, 1980, 94 Stat. 2650, provided for deferral of interim payments to be made during last twenty-one days of fiscal year 1981 until fiscal year 1982, prior to repeal by Pub. L. 97–35, title XXI, § 2155,Aug. 13, 1981, 95 Stat. 802.
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