Services of Physicians Furnished in Providers or to Patients of Providers

80 - Services of Physicians Furnished in Providers or to Patients of Providers (Rev. 1, 10-01-03) B3-15014 This section sets forth special conditions that govern payments for services that physicians furnish in, or to patients of, providers of services including hospitals, SNFs, or Comprehensive Outpatient Rehabilitation Facilities (CORFs). If physicians are compensated for their services by a provider or another entity, the compensation they receive must be allocated among the various types of services they furnish. The A/B MAC (A) pays for services that physicians furnish to the provider. Physician services to the provider include, but are not limited to, standby surgical services. Payment for physicians’ services to individual patients that meet the conditions in subsection A is made under the physicians fee schedule. However: • Payment for physicians’ services furnished in teaching settings is subject to the additional conditions in §100; • Payment for physicians’ services furnished to ESRD patients is subject to additional requirements in Chapter 8, and • The A/B MAC (A) pays for the services of residents, as well as for physicians who are licensed to practice only in the provider setting, as provider services. (See §100.2) A. Conditions for Physician Fee Schedule Payment for Physicians’ Services to Patients in Providers 1. General A/B MACs (B) pay for physicians’ services to patients of providers on a fee schedule basis only if the following requirements are met: • The services are personally furnished for an individual patient by a physician; • The services contribute directly to the diagnosis or treatment or an individual patient; • The services ordinarily require performance by a physician; and • In the case of anesthesiology, radiology, or pathology/laboratory services, certain additional requirements in §§50, 60, and 70 are met. 2. Services of Physicians to Patients in Providers If a physician furnishes services to a patient in a hospital or SNF that do not meet the requirements in §80.A.1, above, but are related to patient care, the services may be covered as provider services and paid by the A/B MAC (A) within the applicable Prospective Payment System (PPS) rate. 3. Effect of Billing Charges for Physician Services to Provider If services furnished by a physician to a provider may be paid by the A/B MAC (A), neither the provider nor the physician may seek fee schedule payments from the A/B MAC (B), the beneficiary, or another insurer. A/B MACs (B) must report any situation in which this happens to the RO unless it is clearly an isolated case of billing error. 4. Effect of Assumption of Operating Costs If a physician or an entity enters into an agreement (such as a lease or concession) with a provider under which the physician (or entity) assumes some or all of the operating costs of the provider department: • A/B MACs (B) make fee schedule payments only for physicians’ services to individual patients; • The physician (or other entity) must make its books and records available to the provider and the A/B MAC (A), as necessary, to verify the nature and extent of the costs of the services furnished by the physician (or other entity); and • The lessee’s costs associated with producing these services, including overhead, supplies, equipment, and the costs of employing nonphysician personnel are payable by the A/B MAC (A) as provider services.