(a) Except as specified in paragraphs (b), (c), and (d) of this section, Medicare pays no more for Part B medical and other health services than the “reasonable charge” for such service. The reasonable charge is determined by the carriers (subject to any deductible and coinsurance amounts as specified in §§ 410.152 and 410.160 of this chapter).
(b) Part B of Medicare pays on the basis of “reasonable cost” (see part 413 of this chapter) for certain institutional services, certain services furnished under arrangements with institutions, and services furnished by entities that elect to be paid on a cost basis (including health maintenance organizations, rural health clinics, FQHCs that are authorized to bill under a reasonable cost system, and end-stage renal disease facilities).
(c) Carriers will determine the reasonable charge on the basis of the criteria specified in § 405.502, and the customary and prevailing charge screens in effect when the service was furnished. (Also see §§ 415.55 through 415.70 and §§ 415.100 through 415.130 of this chapter, which pertain to the determination of reimbursement for services performed by hospital-based physicians.) However, when services are furnished more than 12 months before the beginning of the fee screen year (January 1 through December 30) in which a request for payment is made, payment is based on the customary and prevailing charge screens in effect for the fee screen year that ends immediately preceding the fee screen year in which the claim or request for payment is made.
(d) Payment under Medicare Part B for durable medical equipment and prosthetic and orthotic devices is determined in accordance with the provisions of subpart D of part 414 of this chapter.
[47 FR 63274, Dec. 31, 1981, as amended at 51 FR 34978, Oct. 1, 1986; 51 FR 37911, Oct. 27, 1986; 54 FR 9003, Mar. 2, 1989; 57 FR 24975, June 12, 1992; 57 FR 33896, July 31, 1992; 57 FR 57688, Dec. 7, 1992; 60 FR 63176, Dec. 8, 1995; 79 FR 25473, May 2, 2014]
Notes of Decisions
United States v. Alexander Popov, 742 F.3d 911 (9th Cir. 2014).
“§ 1395 (a)(1); 42 C.F.R. §§ 405.501 , 410.152(b). The provider may pursue recovery of the remaining twenty percent of the allowed amount from the patient directly.”
Popkin v. Burwell, 172 F. Supp. 3d 161 (D.D.C. 2016).
“§ 1395u(b)(3); 42 C.F.R. § 405.501 et seq.; Isaacs v. Bowen, 865 F.”
Harry M. Kechijian v. Joseph A. Califano, Jr., Etc., 621 F.2d 1 (1st Cir. 1980).
“Determination of whether the charges are reasonable is made by the carrier, 42 C.F.R. §§ 405.501 -.508, whose duty it is to institute methods of assuring that payments made under Part B “are for covered services which are medically necessary”.”
Martin v. Shalala, 63 F.3d 497 (7th Cir. 1995).
· cites it 2× “§ 1395u(b)(3)(L); 42 C.F.R. § 405.501 et seq. The amount established by the carrier as “reasonable” is considered a “screen” above which a charge is not reasonable and reimbursement will not be paid.”
United States v. LaHue, 998 F. Supp. 1182 (D. Kan. 1998).
“at § 13951(a)(1); " see also 42 C.F.R. § 405.501 , et seq. The beneficiary is responsible for a “copayment” of the remaining 20% of the allowed charge.”
Anderson v. Bowen, 881 F.2d 1 (2d Cir. 1989).
“§ 1395u(b)(3), 42 C.F.R. §§ 405.501 et seq. While the statute and regulations instruct the carrier to take into account certain criteria in ascertaining the reasonableness of a charge for which a claim reimbursement is sought, additional factors found by the carrier to be…”
Cosgrove v. Bowen, 649 F. Supp. 1433 (S.D.N.Y. 1986).
“42 C.F.R. § 405.501 . Insurance *1435 carriers are instructed to exercise judgment in reviewing claims so that determinations of reasonable charges are “realistic and equitable.”
Walsh v. McGee, 899 F. Supp. 1232 (S.D.N.Y. 1995).
“§§ 1395u(b)(3), 1395y(a); 42 C.F.R. §§ 405.501 , 421.200. While the Act instructs carriers to consider specific criteria in making these determinations, a carrier may take into account additional factors that it deems necessary to its evaluation.”
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