C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 413—PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES; PAYMENT FOR ACUTE KIDNEY INJURY DIALYSIS › Subpart H—Payment for End-Stage Renal Disease (ESRD) Ser…

42 C.F.R. § 413.170

Scope

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This subpart implements sections 1881(b)(2), (b)(4), (b)(7), and (b)(12) through (b)(14) of the Act by—

(a) Setting forth the principles and authorities under which CMS is authorized to establish a prospective payment system for outpatient maintenance dialysis services in or under the supervision of an ESRD facility that meets the conditions of coverage in part 494 of this chapter and as defined in § 413.171(c).

(b) Providing procedures and criteria under which a pediatric ESRD facility (an ESRD facility with at least a 50 percent pediatric patient mix as specified in § 413.184 of this subpart) may receive an exception to its prospective payment rate prior to January 1, 2011; and

(c) Establishing procedures that a facility must follow to appeal its payment amount under the prospective payment system.

[62 FR 43668, Aug. 15, 1997, as amended at 70 FR 70330, Nov. 21, 2005; 73 FR 20474, Apr. 15, 2008; 75 FR 49198, Aug. 12, 2010]
Notes of Decisions
Cited in 9 cases, 1994–2009 · leading case: Dialysis Clinic, Inc. v. Leavitt, 518 F. Supp. 2d 197 (D.D.C. 2007).
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Dialysis Clinic, Inc. v. Leavitt, 518 F. Supp. 2d 197 (D.D.C. 2007). · cites it 6× “Specifically, DCI challenges the decision of the Administrator of the Centers for Medicare and Medicaid Services (“CMS”) to deny reimbursement pursuant to 42 C.F.R. § 413.170 (e) (“ § 413.170(e)”) for bad debts relating to the “separately billed items” category of services.”
St. Luke's Hosp. v. Thompson, 224 F. Supp. 2d 1 (D.D.C. 2002). · cites it 7× “Subsequently, the Secretary promulgated 42 C.F.R. § 413.170 (1993), 5 which provided that the Health Care Financing Administration (“HCFA”) 6 may grant an exception to the composite rate if the dialysis provider demonstrates with convincing objective evidence that its total per…”
Snt Lukes Hosp v. Thompson, Tommy G., 355 F.3d 690 (D.C. Cir. 2004). · cites it 3× “” 42 C.F.R. § 413.170 (g) (1993). “Atypical service intensity (patient mix)” tops the list of criteria.”
Child.'s Hosp. of Buffalo v. Apfel, 110 F. Supp. 2d 158 (W.D.N.Y. 2000). · cites it 10× “172 (b), unless it successfully requests an exception pursuant to 42 C.F.R. § 413.170 . Requests for exceptions are required to be made within 180 days after either notification of a new prospective payment rate, or an extraordinary event with substantial cost effects.”
Kidney Ctr Hlywd v. Shalala, Donna E., 133 F.3d 78 (D.C. Cir. 1998). · cites it 2× “§ 1395rr(b)(2)(A); 42 C.F.R. § 413.170 (b)(1), (d) (1996). 1 If, after making reasonable collection efforts, the provider is unable to collect the 20% co-payment, then the uncollected amount is considered a “bad debt.”
Univ. of Cincinnati v. Shalala, 867 F. Supp. 1325 (S.D. Ohio 1994). · cites it 12× “§ 1395rr(b)(7) and regulatory authority at 42 C.F.R. §§ 413.170 (f) and (g), HCFA has the authority to grant qualifying providers, such as plaintiff, an exception from the standard composite rate of reimbursement.”
Child.'s Hosp. of Buffalo v. Shalala, 2 F. App'x 141 (2d Cir. 2001). · cites it 2× “Pursuant to 42 C.F.R. § 413.170 (f)(4)©, “[a] facility must request an exception to its payment rate within 180 days after .”
Loma Linda Univ. Med. Ctr. v. Leavitt (D.D.C. 2009). “42 C.F.R. § 413.170 (a) (2000).4 Medicare reimbursement payments are determined by a method (or methods) for determining prospectively the amounts of payments to be made for dialysis services furnished by providers of services[.”
Gundersen Lutheran Med. Ctr., Inc. v. Leavitt (D.D.C. 2009). “2 42 C.F.R. § 413.170 (a) (2001).3 Medicare reimbursement payments are determined by a method (or methods) for determining prospectively the amounts of payments to be made for dialysis services furnished by providers of services[.”
— 42 C.F.R. § 413.170(f) — 1 case
Child.'s Hosp. of Buffalo v. Apfel, 110 F. Supp. 2d 158 (W.D.N.Y. 2000). “172 (b), unless it successfully requests an exception pursuant to 42 C.F.R. § 413.170 . Requests for exceptions are required to be made within 180 days after either notification of a new prospective payment rate, or an extraordinary event with substantial cost effects.”
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