42 C.F.R. § 447.10

Prohibition against reassignment of provider claims

Read at: eCFRecfr.gov CornellLII GovInfogovinfo.gov CasesGoogle Scholar

(a) Basis and purpose. This section implements section 1902(a)(32) of the Act which prohibits State payments for Medicaid services to anyone other than a provider or beneficiary, under an assignment, power of attorney, or similar arrangement, except in specified circumstances.

(b) Definitions. For purposes of this section:

Facility means an institution that furnishes health care services to inpatients.

Factor means an individual or an organization, such as a collection agency or service bureau, that advances money to a provider for accounts receivable that the provider has assigned, sold or transferred to the individual organization for an added fee or a deduction of a portion of the accounts receivable. Factor does not include a business representative as described in paragraph (f) of this section.

Organized health care delivery system means a public or private organization for delivering health services. It includes, but is not limited to, a clinic, a group practice prepaid capitation plan, and a health maintenance organization.

(c) State plan requirements. A State plan must provide that the requirements of paragraphs (d) through (h) of this section are met.

(d) Who may receive payment. Payment may be made only—

(1) To the provider; or

(2) To the beneficiary if he is a noncash beneficiary eligible to receive the payment under § 447.25; or

(3) In accordance with paragraphs (e), (f), and (g) of this section.

(e) Reassignments. Payment may be made in accordance with a reassignment from the provider to a government agency or reassignment by a court order.

(f) Business agents. Payment may be made to a business agent, such as a billing service or an accounting firm, that furnishes statements and receives payments in the name of the provider, if the agent's compensation for this service is—

(1) Related to the cost of processing the billing;

(2) Not related on a percentage or other basis to the amount that is billed or collected; and

(3) Not dependent upon the collection of the payment.

(g) Individual practitioners. Payment may be made to—

(1) The employer of the practitioner, if the practitioner is required as a condition of employment to turn over his fees to the employer;

(2) The facility in which the service is provided, if the practitioner has a contract under which the facility submits the claim; or

(3) A foundation, plan, or similar organization operating an organized health care delivery system, if the practitioner has a contract under which the organization submits the claim.

(h) Prohibition of payment to factors. Payment for any service furnished to a beneficiary by a provider may not be made to or through a factor, either directly or by power of attorney.

(i) The payment prohibition in section 1902(a)(32) of the Act and paragraph (d) of this section does not apply to payments to a third party on behalf of an individual practitioner for benefits such as health insurance, skills training, and other benefits customary for employees, in the case of a class of practitioners for which the Medicaid program is the primary source of revenue, if the practitioner voluntarily consents to such payments to third parties on the practitioner's behalf.

[43 FR 45253, Sept. 29, 1978, as amended at 46 FR 42672, Aug. 24, 1981; 61 FR 38398, July 24, 1996; 79 FR 3039, Jan. 16, 2014; 84 FR 19728, May 6, 2019; 87 FR 29690, May 16, 2022]

Notes of Decisions

Cited in 20 cases (1 in the last 5 years), 1982–2022 · leading case: Olszewski v. Scripps Health, 69 P.3d 927 (Cal. 2003).

Sort: Relevance Newest Treatment

Olszewski v. Scripps Health, 69 P.3d 927 (Cal. 2003). · cites it 2× “*12 § 1396a(a)(13); 42 C.F.R. § 447.10 (2002).) [6] The plan and the state agency administering that plan must ensure that the rate is "reasonable and adequate to meet the costs that must be incurred by efficiently and economically operated facilities to provide services in…”

Conlan v. Bonta', 125 Cal. Rptr. 2d 788 (Cal. Ct. App. 2002). · cites it 2× “§ 1396a(a)(32); 42 C.F.R. §§ 447.10 (d) & 447.25 (2001)), prohibit it from making reimbursement *759 directly to the recipient rather than to the vendor.”

Teresa Barney & Randy Barney, Bonita Waldron, on Behalf of Themselves & Others Similarly Situated, Intervenor-Appellant v. Holzer Clinic, Ltd., 110 F.3d 1207 (6th Cir. 1997). “§ 1396d “by prescribing requirements applicable to States making direct payments to certain recipients for physicians’ or dentists’ services”); 42 C.F.R. § 447.10 (d)(2). In Ohio, however, all Medicaid payments flow from the state directly to the medical provider; a provider is…”

Al-Shaikh v. State Dep't of Health Care Servs., 230 Cal. Rptr. 3d 832 (Cal. Ct. App. 5th 2018). · cites it 2× “" ( 42 C.F.R. § 447.10 , subd. (a) ; see generally Danvers Pathology Associates, Inc.”

Greenstein, Ex Rel. Horowitz v. Bane, 833 F. Supp. 1054 (S.D.N.Y. 1993). “42 C.F.R. § 447.10 (d); N.Y.Comp.Codes R.”

State v. Vainio, 2001 MT 220 (Mont. 2001). “¶45 Nothing the State or DPHHS can do will change the fact that during the period of alleged fraud, the billing practice at issue in Count I was not illegal.”

9 soc.sec.rep.ser. 122, Medicare&medicaid Gu 34,550 Danvers Pathology Assocs., Inc. v. Charles Atkins, Comm'r, Etc., 757 F.2d 427 (1st Cir. 1985). “See 42 C.F.R. § 447.10 . Third, we find Danvers’ strongest argument — based on exception (A)(ii) of subsection 32 — plausible but insufficient to turn the tide.”

Krieger v. Krauskopf, 121 A.D.2d 448 (N.Y. App. Div. 1986). “Federal statute and *450 regulation further provide that a State may make payments under the Medicaid program to service providers or to individuals if the State plan so provides (see, 42 USC § 1396a [a] [32]; 42 CFR 447.10 [d]; 447.25). New York’s Social Services Law § 367-a…”

Delores Polk v. Betty Yee, 36 F.4th 939 (9th Cir. 2022). “29675 (May 16, 2022) (codified at 42 C.F.R. § 447.10 (i)). But even if CMS maintained its old interpretation, appellants still cannot show that Congress intended to confer an enforceable right.”

Carroll v. DeBuono, 998 F. Supp. 190 (N.D.N.Y. 1998). “§§ 1396a(a)(27), (32); 42 C.F.R. § 447.10 . ' Defendants further assert that the Regulation is in* harmony with the Act’s goal of preventing fraud.”

Banks v. Sec'y of the Indiana Fam. & Soc. Servs. Admin., 790 F. Supp. 1427 (N.D. Ind. 1992). “42 C.F.R. § 447.10 (d). As noted above, the medical provider must accept the payment from Medicaid as payment in full and may not seek additional payment from the Medicaid recipient.”

McCrann v. NC Dep't of Health & Human Servs., Div. of Mental Health, 704 S.E.2d 899 (N.C. Ct. App. 2011). · cites it 2× “§ 1396a(a)(32) (2009); 42 C.F.R. §§ 447.10 (d) & 447.25 (2009). We conclude petitioners are entitled to reimbursement.”

Show all 20 citing cases →

Annotations are extracted automatically from the opinions in the Syfert caselaw corpus and ranked by authority, recency, and treatment. Dots show Syfertize treatment of the citing case itself.