42 U.S.C. § 1395pp : US Code - Section 1395PP: Limitation on liability where claims are disallowed

Search 42 U.S.C. § 1395pp : US Code - Section 1395PP: Limitation on liability where claims are disallowed

(a) Conditions prerequisite to payment for items and services
notwithstanding determination of disallowance
Where -
(1) a determination is made that, by reason of section
1395y(a)(1) or (9) of this title or by reason of a coverage
denial described in subsection (g) of this section, payment may
not be made under part A or part B of this subchapter for any
expenses incurred for items or services furnished an individual
by a provider of services or by another person pursuant to an
assignment under section 1395u(b)(3)(B)(ii) of this title, and
(2) both such individual and such provider of services or such
other person, as the case may be, did not know, and could not
reasonably have been expected to know, that payment would not be
made for such items or services under such part A or part B of
this subchapter,
then to the extent permitted by this subchapter, payment shall,
notwithstanding such determination, be made for such items or
services (and for such period of time as the Secretary finds will
carry out the objectives of this subchapter), as though section
1395y(a)(1) and section 1395y(a)(9) of this title did not apply and
as though the coverage denial described in subsection (g) of this
section had not occurred. In each such case the Secretary shall
notify both such individual and such provider of services or such
other person, as the case may be, of the conditions under which
payment for such items or services was made and in the case of
comparable situations arising thereafter with respect to such
individual or such provider or such other person, each shall, by
reason of such notice (or similar notices provided before the
enactment of this section), be deemed to have knowledge that
payment cannot be made for such items or services or reasonably
comparable items or services. Any provider or other person
furnishing items or services for which payment may not be made by
reason of section 1395y(a)(1) or (9) of this title or by reason of
a coverage denial described in subsection (g) of this section shall
be deemed to have knowledge that payment cannot be made for such
items or services if the claim relating to such items or services
involves a case, provider or other person furnishing services,
procedure, or test, with respect to which such provider or other
person has been notified by the Secretary (including notification
by a utilization and quality control peer review organization) that
a pattern of inappropriate utilization has occurred in the past,
and such provider or other person has been allowed a reasonable
time to correct such inappropriate utilization.
(b) Knowledge of person or provider that payment could not be made;
indemnification of individual
In any case in which the provisions of paragraphs (1) and (2) of
subsection (a) of this section are met, except that such provider
or such other person, as the case may be, knew, or could be
expected to know, that payment for such services or items could not
be made under such part A or part B of this subchapter, then the
Secretary shall, upon proper application filed within such time as
may be prescribed in regulations, indemnify the individual
(referred to in such paragraphs) for any payments received from
such individual by such provider or such other person, as the case
may be, for such items or services. Any payments made by the
Secretary as indemnification shall be deemed to have been made to
such provider or such other person, as the case may be, and shall
be treated as overpayments, recoverable from such provider or such
other person, as the case may be, under applicable provisions of
law. In each such case the Secretary shall notify such individual
of the conditions under which indemnification is made and in the
case of comparable situations arising thereafter with respect to
such individual, he shall, by reason of such notice (or similar
notices provided before the enactment of this section), be deemed
to have knowledge that payment cannot be made for such items or
services. No item or service for which an individual is indemnified
under this subsection shall be taken into account in applying any
limitation on the amount of items and services for which payment
may be made to or on behalf of the individual under this
subchapter.
(c) Knowledge of both provider and individual to whom items or
services were furnished that payment could not be made
No payments shall be made under this subchapter in any cases in
which the provisions of paragraph (1) of subsection (a) of this
section are met, but both the individual to whom the items or
services were furnished and the provider of service or other
person, as the case may be, who furnished the items or services
knew, or could reasonably have been expected to know, that payment
could not be made for items or services under part A or part B of
this subchapter by reason of section 1395y(a)(1) or (a)(9) of this
title or by reason of a coverage denial described in subsection (g)
of this section.
(d) Exercise of rights
In any case arising under subsection (b) of this section (but
without regard to whether payments have been made by the individual
to the provider or other person) or subsection (c) of this section,
the provider or other person shall have the same rights that an
individual has under sections 1395ff(b) and 1395u(b)(3)(C) of this
title (as may be applicable) when the amount of benefit or payments
is in controversy, except that such rights may, under prescribed
regulations, be exercised by such provider or other person only
after the Secretary determines that the individual will not
exercise such rights under such sections.
(e) Payment where beneficiary not at fault
Where payment for inpatient hospital services or extended care
services may not be made under part A of this subchapter on behalf
of an individual entitled to benefits under such part solely
because of an unintentional, inadvertent, or erroneous action with
respect to the transfer of such individual from a hospital or
skilled nursing facility that meets the requirements of section
1395x(e) or (j) of this title by such a provider of services acting
in good faith in accordance with the advice of a utilization review
committee, quality control and peer review organization, or fiscal
intermediary, or on the basis of a clearly erroneous administrative
decision by a provider of services, the Secretary shall take such
action with respect to the payment of such benefits as he
determines may be necessary to correct the effects of such
unintentional, inadvertent, or erroneous action.
(f) Presumption with respect to coverage denial; rebuttal;
requirements; "fiscal intermediary" defined
(1) A home health agency which meets the applicable requirements
of paragraphs (3) and (4) shall be presumed to meet the requirement
of subsection (a)(2) of this section.
(2) The presumption of paragraph (1) with respect to specific
services may be rebutted by actual or imputed knowledge of the
facts described in subsection (a)(2) of this section, including any
of the following:
(A) Notice by the fiscal intermediary of the fact that payment
may not be made under this subchapter with respect to the
services.
(B) It is clear and obvious that the provider should have known
at the time the services were furnished that they were excluded
from coverage.
(3) The requirements of this paragraph are as follows:
(A) The agency complies with requirements of the Secretary
under this subchapter respecting timely submittal of bills for
payment and medical documentation.
(B) The agency program has reasonable procedures to notify
promptly each patient (and the patient's physician) where it is
determined that a patient is being or will be furnished items or
services which are excluded from coverage under this subchapter.
(4)(A) The requirement of this paragraph is that, on the basis of
bills submitted by a home health agency during the previous
quarter, the rate of denial of bills for the agency by reason of a
coverage denial described in subsection (g) of this section does
not exceed 2.5 percent, computed based on visits for home health
services billed.
(B) For purposes of determining the rate of denial of bills for a
home health agency under subparagraph (A), a bill shall not be
considered to be denied until the expiration of the 60-day period
that begins on the date such bill is denied by the fiscal
intermediary, or, with respect to such a denial for which the
agency requests reconsideration, until the fiscal intermediary
issues a decision denying payment for such bill.
(5) In this subsection, the term "fiscal intermediary" means,
with respect to a home health agency, an agency or organization
with an agreement under section 1395h of this title with respect to
the agency.
(6) The Secretary shall monitor the proportion of denied bills
submitted by home health agencies for which reconsideration is
requested, and shall notify Congress if the proportion of denials
reversed upon reconsideration increases significantly.
(g) Coverage denial defined
The coverage denial described in this subsection is -
(1) with respect to the provision of home health services to an
individual, a failure to meet the requirements of section
1395f(a)(2)(C) of this title or section 1395n(a)(2)(A) of this
title in that the individual -
(A) is or was not confined to his home, or
(B) does or did not need skilled nursing care on an
intermittent basis; and
(2) with respect to the provision of hospice care to an
individual, a determination that the individual is not terminally
ill.
(h) Supplier responsibility for items furnished on assignment basis
If a supplier of medical equipment and supplies (as defined in
section 1395m(j)(5) of this title) -
(1) furnishes an item or service to a beneficiary for which no
payment may be made by reason of section 1395m(j)(1) of this
title;
(2) furnishes an item or service to a beneficiary for which
payment is denied in advance under section 1395m(a)(15) of this
title; or
(3) furnishes an item or service to a beneficiary for which no
payment may be made by reason of section 1395m(a)(17)(B) of this
title,
any expenses incurred for items and services furnished to an
individual by such a supplier on an assignment-related basis shall
be the responsibility of such supplier. The individual shall have
no financial responsibility for such expenses and the supplier
shall refund on a timely basis to the individual (and shall be
liable to the individual for) any amounts collected from the
individual for such items or services. The provisions of section
1395m(a)(18) of this title shall apply to refunds required under
the previous sentence in the same manner as such provisions apply
to refunds under such section.