42 CFR 415.102 - Conditions for fee schedule payment for physician services to beneficiaries in providers.
(a)General rule. If the physician furnishes services to beneficiaries in providers, the carrier pays on a fee schedule basis provided the following requirements are met:
(3) The services ordinarily require performance by a physician.
(b)Exception. If a physician furnishes services in a provider that do not meet the requirements in paragraph (a) of this section, but are related to beneficiary care furnished by the provider, the intermediary pays for those services, if otherwise covered. The intermediary follows the rules in §§ 415.55 and 415.60 for payment on the basis of reasonable cost or PPS, as appropriate.
(c)Effect of billing charges for physician services to a provider.
(1) If a physician furnishes services that may be paid under the reasonable cost rules in § 415.55 or § 415.60, and paid by the intermediary, or would be paid under those rules except for the PPS rules in part 412 of this chapter, and under the payment rules for GME established by §§ 413.75 through 413.83 of this chapter, neither the provider nor the physician may seek payment from the carrier, beneficiary, or another insurer.
(2) If a physician furnishes services to an individual beneficiary that do not meet the applicable conditions in §§ 415.120 (concerning conditions for payment for radiology services) and 415.130 (concerning conditions for payment for physician pathology services), the carrier does not pay on a fee schedule basis.
(3) If the physician, the provider, or another entity bills the carrier or the beneficiary or another insurer for physician services furnished to the provider, as described in § 415.55(a), CMS considers the provider to which the services are furnished to have violated its provider participation agreement, and may terminate that agreement. See part 489 of this chapter for rules governing provider agreements.
(d)Effect of physician assumption of operating costs. If a physician or other entity enters into an agreement (such as a lease or concession) with a provider, and the physician (or entity) assumes some or all of the operating costs of the provider department in which the physician furnishes physician services, the following rules apply:
(2) To the extent the provider incurs a cost payable on a reasonable cost basis under part 413 of this chapter, the intermediary pays the provider on a reasonable cost basis for the costs associated with producing these services, including overhead, supplies, equipment costs, and services furnished by nonphysician personnel.
(4) The physician (or other entity) must make its books and records available to the provider and the intermediary as necessary to verify the nature and extent of the costs of the services furnished by the physician (or other entity).
- 42 CFR 412.50 — Furnishing of Inpatient Hospital Services Directly or Under Arrangements.
- 42 CFR 415.130 — Conditions for Payment: Physician Pathology Services.
- 42 CFR 412.509 — Furnishing of Inpatient Hospital Services Directly or Under Arrangement.
- 42 CFR 489.21 — Specific Limitations on Charges.
- 42 CFR 415.55 — General Payment Rules.
- 42 CFR 412.604 — Conditions for Payment Under the Prospective Payment System for Inpatient Rehabilitation Facilities.
- 42 CFR 411.15 — Particular Services Excluded From Coverage.
- 42 CFR 415.120 — Conditions for Payment: Radiology Services.
- 42 CFR 409.10 — Included Services.
- 42 CFR 415.170 — Conditions for Payment on a Fee Schedule Basis for Physician Services in a Teaching Setting.
- 42 CFR 489.20 — Basic Commitments.
- 42 CFR 415.208 — Services of Moonlighting Residents.
- 42 CFR 415.110 — Conditions for Payment: Medically Directed Anesthesia Services.
- 42 CFR 419.22 — Hospital Services Excluded From Payment Under the Hospital Outpatient Prospective Payment System.
- 42 CFR 412.404 — Conditions for Payment Under the Prospective Payment System for Inpatient Hospital Services of Psychiatric Facilities.
- 42 CFR 410.43 — Partial Hospitalization Services: Conditions and Exclusions.
- 42 CFR 410.42 — Limitations on Coverage of Certain Services Furnished to Hospital Outpatients.
- 42 CFR 412.71 — Determination of Base-Year Inpatient Operating Costs.
- 42 CFR 415.60 — Allocation of Physician Compensation Costs.