Meaning of Providers and Suppliers

2002 - Meaning of Providers and Suppliers (Rev .40, Issued: 03-20-09, Effective: 03-20-09, Implementation: 03-20-09) The Medicare law differentiates between providers and suppliers. The general distinction between providers and suppliers is that providers are parties who care for patients awaiting, receiving, or recuperating from treatment by intervening practitioners. The term suppliers” includes those who furnish goods and services used in care and treatment. Medicaid terminology, by contrast, uses “provider” generically to include all health care vendors. (See 42 CFR 431.107(a) and 433.37.) Medicare providers and suppliers are defined at 42 CFR 498.2. In Medicare, as specified in §1861(u) of the Act, providers include hospitals, critical access hospitals (CAHs), skilled nursing facilities (SNFs), home health agencies (HHAs), hospices and comprehensive outpatient rehabilitation facilities (CORFs). Under §1835(a)(2) of the Act, clinics, rehabilitation agencies, or public health agencies are included as providers if such clinic or agency meets the requirements of §1861(p)(4)(A). Community Mental Health Centers (CMHC) are providers of services for partial hospitalization services only. Providers must meet CoPs or Requirements for SNFs to participate in Medicare. (See definitions at 42 CFR 498.2.) Portable x-ray services, end stage renal disease (ESRD) facilities, ambulatory surgical centers (ASCs), and organ procurement organizations (OPOs) are suppliers that must meet conditions for coverage to participate in Medicare; rural health clinics (RHCs) are suppliers that must meet conditions for certification to participate in Medicare. Federally Qualified Health Centers (FQHCs) are also recognized as suppliers of services and provide ambulatory care services similar to those provided by RHCs. FQHCs may be located in urban, as well as rural, areas. FQHCs are required to meet the same health and safety standards as RHCs, with the exception of the certification procedures. FQHCs self- attest to their compliance with Medicare conditions for coverage and are only surveyed by CMS in connection with complaint investigations. The above types of suppliers are distinguished from other suppliers, e.g., pharmacies, prosthesis suppliers, etc., for which there are no conditions for coverage or certification, and which qualify for Medicare through the enrollment process. Laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings are yet another category of suppliers and must meet Clinical Laboratory Improvements of 1988 Act (CLIA) requirements. As previously stated, Medicaid does not distinguish between providers and suppliers. Section 1902(a)(27) of the Act provides for agreements with every person or institution providing services under the State plan. 42 CFR 431.107(a) refers to all providers of services (including individual practitioners and groups of practitioners).