Medicare Managed Care Manual (Pub. 100-16), Ch. 18b § 20
Physician and Other Part B Services Furnished Directly by the
20 - Physician and Other Part B Services Furnished Directly by the
HCPP
(Rev. 30, 09-05-03)
Amounts paid by HCPPs to physicians who are employees of the HCPP or a related
facility by common ownership or control will be found reasonable to the extent they
commensurate with amounts paid for similar services performed by similar physicians in
the same or similar locality.
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The amount paid (e.g., salaries, capitation, fixed sum, incentive payments) as well as
fringe benefits will be compared in the aggregate to that received by physicians generally
in the community and amounts received by physicians in similar organizations.
Compensation paid by the HCPP for personal services of physicians (e.g., salaries,
wages, incentive payments, fringe benefits) must be distinguished from payments to
physicians for nonpersonal services (e.g., expenses attributable to facilities, equipment,
support personnel, supplies), in determining whether compensation is allowable.
Physician compensation may take various forms, but the aggregate compensation must be
reasonable in relation to the services personally furnished. If aggregate physician
compensation costs exceed what is normally incurred, the excess is not considered
reasonable. Costs incurred for other Part B items and services, including payments to
physicians for nonpersonal services, will be found to be reasonable to the extent they:
• Are commensurate with amounts paid for similar items and services furnished by
similar personnel and suppliers in the same or similar locality;
• Do not exceed those that a prudent and cost conscious buyer would incur to
purchase those services.