C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES › Subpart B—Physicians and Other Practitioners

42 C.F.R. § 414.48

Limits on actual charges of nonparticipating suppliers

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(a) General rule. A supplier, as defined in § 400.202 of this chapter, who is nonparticipating and does not accept assignment may charge a beneficiary an amount up to the limiting charge described in paragraph (b) of this section.

(b) Specific limits. For items or services paid under the physician fee schedule, the limiting charge is 115 percent of the fee schedule amount for nonparticipating suppliers. For items or services CMS excludes from payment under the physician fee schedule (in accordance with section 1848 (j)(3) of the Act), the limiting charge is 115 percent of 95 percent of the payment basis applicable to participating suppliers as calculated in § 414.20(b).

[58 FR 63687, Dec. 2, 1993, as amended at 62 FR 59102, Oct. 31, 1997]
Notes of Decisions
Cited in 1 case, 1993–1993 · leading case: Medicare Beneficiaries Def. Fund v. Mem'l Sloan-Kettering Cancer Ctr., 159 Misc. 2d 442 (N.Y. Sup. Ct. 1993).
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Medicare Beneficiaries Def. Fund v. Mem'l Sloan-Kettering Cancer Ctr., 159 Misc. 2d 442 (N.Y. Sup. Ct. 1993). “To distinguish between services rendered in such institutions by physicians who bill directly and by employed physicians makes little sense.”
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