Conditions for payment under the IPF Prospective Payment System

10.4 - Conditions for payment under the IPF Prospective Payment System (Rev. 253, Issued: 12- 14-18, Effective: 01-16-19, Implementation: 01- 16-19) As required in 42 CFR 412.404, effective for cost reporting periods beginning on or after January 1, 2005, an inpatient psychiatric facility (IPF), defined as an inpatient psychiatric hospital or distinct psychiatric unit of an acute care hospital or CAH, must meet the following conditions to receive payment under the IPF prospective payment system (PPS) for inpatient hospital services furnished to Medicare Part A fee-for-service beneficiaries. If an IPF fails to comply fully with these conditions, CMS may, as appropriate withhold (in full or in part) or reduce Medicare payment to the IPF until the facility provides adequate assurances of compliance, or CMS may classify the IPF as an inpatient hospital that is subject to the requirements for hospitals and paid under the hospital Inpatient Prospective Payment System. • IPFs subject to the IPF PPS. Subject to the special payment provisions of §412.22(c), an IPF must meet the general criteria set forth in §412.22. In order to be excluded from the hospital inpatient prospective payment system as specified in §412.1(a)(1), a psychiatric hospital must meet the criteria set forth in §§412.23(a), 482.60, 482.61, and 482.62 and psychiatric units must meet the criteria set forth in §412.25 and §412.27. • Limitations on charges to beneficiaries o Prohibited charges. Except as permitted below, an IPF may not charge a beneficiary for any services for which payment is made by Medicare, even if the facility's cost of furnishing services to that beneficiary is greater than the amount the facility is paid under the IPF PPS. o Permitted charges. An IPF receiving payment under the IPF PPS for a covered hospital stay (that is, a stay that included at least one covered day) may charge the Medicare beneficiary or other person only the applicable deductible and coinsurance amounts under 42 CFR §§409.82, 409.83, and 409.87 and for items or services as specified under 42 CFR §489.20(a). • Furnishing of inpatient hospital services directly or under arrangement. Subject to the provisions of §412.422, the applicable payments made under the IPF PPS are payment in full for all inpatient hospital services, as specified in §409.10. Hospital inpatient services do not include the following: (a) Physicians' services that meet the requirements of 42 CFR §415.102(a) for payment on a fee schedule basis. (b) Physician assistant services, as specified in section 1861(s)(2)(K)(i) of the Act. (c) Nurse practitioners and clinical nurse specialist services, as specified in section 1861(s)(2)(K)(ii) of the Act. (d) Certified nurse midwife services, as specified in section 1861(gg) of the Act. (e) Qualified psychologist services, as specified in section 1861(ii) of the Act. (f) Services of a certified registered nurse anesthetist, as specified in section 1861(bb) of the Act and defined in 42 CFR §410.69. o CMS does not pay providers or suppliers, other than IPFs, for services furnished to a Medicare beneficiary who is an inpatient of the IPF, except for the professional services described in (a) through (f) above. o The IPF must furnish all necessary covered services to a Medicare beneficiary who is an inpatient of the IPF, either directly or under arrangements (as specified in 42 CFR §409.3). • Reporting and recordkeeping requirements. All IPFs participating in the IPF PPS must meet the recordkeeping and cost reporting requirements as specified in 42 CFR §§412.27(c), 413.20, 413.24, and 482.61. Medical record requirements are detailed in section 30 of this chapter. An IPF may not file its cost reports as an “all-inclusive” provider unless that all- inclusive status has been previously approved by its Medicare Administrative Contractor, in accordance with the Provider Reimbursement Manual, Part 1, chapter 22, section 2208.