[Federal Register Volume 59, Number 35 (Tuesday, February 22, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-3608]


[[Page Unknown]]

[Federal Register: February 22, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
42 CFR Part 421

[BPO-111-P]
RIN 0938-AG06

 

Medicare Program; Intermediary and Carrier Functions

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Notice of proposed rulemaking.

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SUMMARY: This proposed rule would bring certain sections of the 
regulations concerning Medicare fiscal intermediaries and carriers into 
conformity with the appropriate sections of Title XVIII of the Social 
Security Act. The rule would distinguish between those functions which 
applicable statutory authorities require to be included in agreements 
with fiscal intermediaries and those functions that, while not required 
to be performed by organizations that have entered into intermediary 
agreements with the Secretary pursuant to section 1816 of the Social 
Security Act, may be included in such agreements at our discretion.
    We would require that the intermediary agreements include, as 
functions, requirements that intermediaries determine proper payment 
amounts and pay bills. All other functions would be optional. We 
propose that all functions for carriers are optional. These changes 
would provide us with the flexibility to transfer functions from one 
intermediary or carrier to another or to otherwise limit the functions 
an intermediary or carrier performs when we determine to do so would 
result in more effective and efficient program administration.
    In addition, we propose a number of technical or clarifying 
revisions concerning carrier payment on a fee schedule basis and the 
distinction between nonrenewal and termination of intermediary 
agreements and carrier contracts.

DATES: Comments will be considered if we receive them at the 
appropriate address, as provided below, no later than 5 p.m. on April 
25, 1994.

ADDRESSES: Mail written comments to the following address: Health Care 
Financing Administration, Department of Health and Human Services, 
Attention: BPO-111-P, P.O. Box 26676, Baltimore, MD 21207.

    If you prefer, you may deliver your comments to one of the 
following addresses:

Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, 
SW., Washington, DC 20201, or
Room 132, East High Rise Building, 6325 Security Boulevard, 
Baltimore, Maryland 21207.

    Due to staffing and resource limitations, we cannot accept 
facsimile (FAX) transmissions. In commenting, please refer to file code 
BPO-111-P. Comments received timely will be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, in room 309-G of the 
Department's offices at 200 Independence Avenue, SW., Washington, DC, 
on Monday through Friday of each week from 8:30 a.m. to 5 p.m. (phone: 
(410) 966-7411).

FOR FURTHER INFORMATION CONTACT: Alan Bromberg, (410) 966-7441

SUPPLEMENTARY INFORMATION:

I. Background

    Intermediary Agreements and Carrier Contracts--Under sections 
1816(a) and 1842(a) of the Social Security Act (the Act), public or 
private organizations and agencies may participate in the 
administration of the Medicare program under agreements or contracts 
entered into with us (on the Secretary's behalf). These Medicare 
contractors are known as fiscal intermediaries (section 1816(a) of the 
Act) and carriers (section 1842(a) of the Act). With certain 
exceptions, intermediaries perform bill processing and benefit payment 
functions for part A of the program (Hospital Insurance) and carriers 
perform claims processing and benefit payment functions for part B of 
the program (Supplementary Medical Insurance).
    Our regulations at 42 CFR 421.100, Intermediary functions, require 
that the agreement between us and a fiscal intermediary specify the 
functions the intermediary is to perform. In addition to any items 
specified by us unique to that intermediary, the regulations require 
that all intermediaries perform activities relating to Medicare 
coverage, fiscal management, provider audits, utilization patterns, 
resolution of cost report disputes, and reconsideration of 
determinations. In addition, the regulations require that all 
intermediaries furnish information and reports, undertake dual 
intermediary responsibilities for service to provider-based Home Health 
Agencies (HHAs) and provider-based hospices, and comply with all 
applicable laws and regulations and with any other terms and conditions 
included in their agreements.
    Similarly, our regulations at 42 CFR 421.200, Carrier functions, 
require that the contract between HCFA and a part B carrier specify the 
functions the carrier is to perform. In addition to any items specified 
by us unique to that carrier, the regulations require that all part B 
carriers perform activities relating to Medicare coverage, payment on a 
cost basis, payment on a charge basis, fiscal management, provider 
audits, utilization patterns and hearings to part B beneficiaries. In 
addition, the regulations require that all carriers furnish information 
and reports, maintain and make available records, and comply with any 
other terms and conditions included in their contracts.
    For both intermediaries and carriers, our regulations at 42 CFR 
421.5, General provisions, state that HCFA has the authority not to 
renew a part A agreement or a part B Contract when it expires. Our 
regulations at 42 CFR 421.126, Termination of agreements, provide the 
Secretary with the authority to terminate fiscal intermediary 
agreements in certain circumstances, while the regulations at 42 CFR 
421.205, Termination by the Secretary, give the Secretary similar 
authority to terminate carrier contracts.

II. Proposed Changes to the Regulations

    As noted earlier, our regulations at Sec. 421.100 for 
intermediaries and Sec. 421.200 for carriers specify a list of 
functions that must, at a minimum, be included in all intermediary 
agreements and carrier contracts. These requirements far exceed those 
of the statute. Section 1816(a) of the Social Security Act requires 
only that an intermediary agreement provide for determination of the 
amount of payments to be made to providers and for the making of such 
payments. Section 1816(a) permits, but does not require, an 
intermediary agreement to include provisions for the intermediary to 
provide consultative services to providers to enable them to establish 
and maintain fiscal records or to otherwise qualify as providers and, 
for those providers to which it makes payments, to serve as a channel 
of communications between us and the providers, to make audits of the 
records of the providers, and to perform such other functions as are 
necessary.
    We believe that section 1816(a) mandates only that an intermediary 
agreement include the functions currently required by Sec. 421.100 
paragraph (a) (Coverage) and paragraph (b) (Fiscal management) of the 
regulations. We believe that the other functions (Sec. 421.100 
paragraphs (c) through (i)) that the regulations currently require to 
be included in all intermediary agreements are not required by statute 
and the mandatory inclusion of them in all agreements limits our 
ability to efficiently and effectively administer the Medicare program.
    Paragraph (a) of section 1842 of the Act, which pertains to carrier 
contracts, requires that the contracts must provide for some or all of 
the functions listed in that paragraph, but does not specify any 
functions which must be included in a carrier contract. As in the case 
of intermediary agreements, our experience has been that mandatory 
inclusion of a long list of functions in all contracts restricts our 
ability to administer the carrier contracts with optimum efficiency and 
effectiveness. We believe that the requirements of the regulations for 
both intermediaries and carriers should be brought into conformity with 
the statutory requirements. Moreover, we believe that such action would 
substantially enhance the efficient and effective administration of the 
Medicare program by giving both HCFA and the contractor community more 
flexibility in their approaches to the performance of intermediary and 
carrier functions.
    We further believe that intermediaries and carriers would benefit 
from the ability to enter voluntarily into regional arrangements for 
the performance of some functions. Intermediaries and carriers have 
shown interest in entering into agreements with other contractors in 
their regions to shift the performance of a given function to a single 
intermediary or carrier that is able to perform the function with the 
greatest efficiency or at the least cost, while another function might 
in turn be shifted to a second contractor. For example, one 
intermediary in a region might perform medical review for the entire 
region, while another would assume the audit function. Under the 
existing requirement that all intermediaries and carriers perform all 
functions, such arrangements are not permitted, except through 
subcontracts, which must be awarded through the competitive procurement 
process and which leave the final responsibility for the performance of 
the function with the original contractor. The proposed change in the 
regulations would provide the intermediaries and carriers with the 
ability to enter into arrangements to transfer formally the entire 
responsibility for performance of a function to other intermediaries 
and carriers, subject to our approval.
    The change would also simplify the process of our paying the 
intermediary or carrier actually performing the function. Under a 
subcontracting arrangement, we pay the contractor that subcontracts out 
the function and that entity, in turn, pays the subcontractor which is 
actually doing the work. Under the proposed change, we would make 
direct payment to the intermediary or carrier performing the function.
    Our conclusion is that the existing regulations, which state that 
intermediary agreements and carrier contracts must include all of the 
functions cited, are not only inconsistent with applicable statutory 
authority, but also are too restrictive. They deny us the flexibility 
to improve the administration of the Medicare program by removing some 
of the functions from an intermediary's agreement or a carrier's 
contract and transferring them to another intermediary or carrier where 
either we or the contractors themselves determine that such action 
would be more efficient than having every intermediary and carrier 
perform all functions specified in the regulations.
    We are proposing to redesignate Sec. 421.100, Intermediary 
functions, as Sec. 421.101, Optional intermediary functions. In a new 
Sec. 421.100, Required intermediary functions, we would specify that 
all agreements must include the functions of coverage (current content 
of Sec. 421.100(a)) and fiscal management (current Sec. 421.100(b)). We 
believe these functions are required to be included in all agreements 
by section 1816(a) of the Act. In the redesignated Sec. 421.101, 
Optional intermediary functions, we would indicate that the 
intermediary agreement may include the functions currently contained in 
Sec. 421.100(c) through 421.100(i). That is, the cumulative effect of 
the change would be to separate the two required functions that must be 
in all intermediary agreements from the remaining functions that may or 
may not be included.
    In Sec. 421.200, Carrier functions, we would change the word 
``must'' to ``may'' in the first sentence, making all the functions 
listed for inclusion in carrier contracts optional. This change would 
reflect section 1842(a) of the Act, which does not list specific 
functions that must be included.
    Our use of the term ``optional'' does not mean that some functions 
might not be performed in some jurisdictions. All functions will 
continue to be performed in all intermediary and carrier jurisdictions. 
``Optional'' in this case means only that HCFA will have the option of 
determining whether a given function should be performed in a specific 
jurisdiction by the intermediary or carrier which normally serves that 
jurisdiction and therefore included in that intermediary's agreement or 
carrier's contract, or should be performed by some other intermediary 
or carrier.
    In Sec. 421.200, we propose to add payment on a fee schedule basis 
as a new function which may be performed by carriers. While the 
original carrier functions included payment on a cost basis and on a 
charge basis, recent statutory changes and corresponding changes in the 
regulations have shifted some classes of physician and Medicare 
suppliers to payment according to fee schedules. However, Sec. 421.200 
has never been updated to recognize these changes. Accordingly, the 
addition of payment on a fee schedule basis as a function which may be 
included in carrier contracts will bring this section of the 
regulations into conformity with current statutory provisions for 
Medicare part B payment.
    In addition, 42 CFR 421.5(d) states that, notwithstanding any of 
the provisions of part 421, HCFA has the authority not to renew an 
agreement or contract when its term expires. Section 421.126(b) allows 
the Secretary to terminate intermediary agreements under certain 
circumstances, while Sec. 421.205 gives the Secretary the authority to 
terminate carrier contracts at any time for cause. The distinction 
between the termination and nonrenewal of an agreement or contract is 
important because the right of an intermediary or carrier to a hearing 
applicable to terminations does not apply to nonrenewals. Consequently, 
we are proposing to revise Secs. 421.5, 421.126, and 421.205 to make 
certain that the distinction between nonrenewals and terminations is 
clear. The proposed changes are not substantive. They are meant to 
reflect existing statutory and regulatory requirements, as well as 
HCFA's longstanding policy and practice, as expressed in the standard 
intermediary agreements and carrier contracts.
    The objective of these proposed changes is to make the regulations 
fully consistent with the relevant statutory authority and to provide, 
as necessary, clarification of the distinction between contract 
nonrenewals and terminations. In addition, the change to the 
regulations concerning mandatory and optional functions will provide us 
with the flexibility to shift non-mandatory functions among 
intermediaries and carriers so that the Medicare program may be 
administered in the most efficient and effective manner possible. We 
anticipate using the authority granted us by this change sparingly. Any 
transfer or consolidation of functions will be determined on a case-by-
case basis, and, prior to taking action in any specific case, we will 
closely study the situation to determine whether the benefits to the 
effective administration of the Medicare program warrant the action. It 
is not our intent at this time to shift functions from intermediaries 
and carriers to any entities except other intermediaries and carriers.

III. Response to Comments

    Because of the large number of items of correspondence we normally 
receive on a proposed rule, we are not able to acknowledge or respond 
to them individually. However, we will consider all comments that we 
receive by the date and time specified in the ``DATES'' section of this 
preamble, and we will respond to them in the preamble to the final 
rule.

IV. Collection of Information Requirement

    This rule contains no information collection requirements. 
Consequently, this rule need not be reviewed by the Office of 
Management and Budget under the authority of the Paperwork Reduction 
Act of 1980 (44 U.S.C. 3501 et seq.).

V. Regulatory Impact Statement

    We generally prepare a regulatory flexibility analysis that is 
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601 
through 612) unless the Secretary certifies that a proposed rule would 
not have a significant economic impact on a substantial number of small 
entities. For purposes of the RFA, intermediaries and carriers are not 
considered to be small entities that will be affected as a result of 
these regulations. Individuals and States are not included in the 
definition of a small entity.
    Also, section 1102(b) of the Act requires the Secretary to prepare 
a regulatory impact analysis if a proposed rule may have a significant 
impact on the operations of a substantial number of small rural 
hospitals. This analysis must conform to the provisions of section 603 
of the RFA. For purposes of section 1102(b) of the Act, we consider a 
small rural hospital as a hospital that is located outside of a 
Metropolitan Statistical Area and has fewer than 50 beds.
    This proposed rule would potentially affect the 47 Medicare part A 
intermediaries and 33 part B carriers with agreements or contracts with 
HCFA to make payments to Medicare providers and beneficiaries for 
covered services and to perform certain other functions currently 
described in Sec. 421.100 for intermediaries and Sec. 421.200 for 
carriers. Under this proposed rule, we would have authority to redefine 
intermediary agreement and carrier contract requirements and remove 
functions from some contractors and transfer them to other contractors. 
We would also be able to consolidate some tasks under one contractor in 
regions where several contractors are all performing the same functions 
simultaneously.
    The proposed rule would also add payment on a fee schedule basis as 
a function which may be included in carrier contracts and distinguishes 
between contract nonrenewals and terminations. This proposed rule would 
make the regulations more consistent with the relevant statutory 
authority and promote the more effective and efficient administration 
of the Medicare program. Service to beneficiaries and Medicare 
providers would not be disrupted in the affected regions.
    Implementing this proposed rule would not create any additional 
expenses but should enable the Medicare program to realize savings in 
administrative costs. At present, we are unable to estimate the 
potential dollar amount of these savings.
    We evaluated the potential impact of these regulations changes on 
intermediaries and carriers for purposes of determining whether a 
regulatory flexibility analysis is required. We believe that the 
effects or the changes will be minimal. Almost all of the present 
contractors have been performing the functions for a number of years 
and have developed efficiencies that would argue against our needlessly 
altering their functions. Therefore, it is not our intention to use the 
flexibility of this regulation to make wholesale changes.
    Consequently, we have determined, and the Secretary certifies, that 
this proposed rule would not result in a significant impact on a 
substantial number of small entities. Similarly, the Secretary 
certifies that it would not have a significant effect on the operations 
of a substantial number of small rural hospitals. Therefore, we are not 
preparing analyses for either the RFA or section 1102(b) of the Act.
    In accordance with the provisions of Executive Order 12866 this 
regulation was reviewed by the Office of Management and Budget.

List of Subjects in 42 CFR Part 421

    Administrative practice and procedure, Health facilities, Health 
professions, Medicare, Reporting and recordkeeping requirements.

    42 CFR part 421 would be amended as set forth below.

PART 421--INTERMEDIARIES AND CARRIERS

    1. The authority citation for part 421 continues to read as 
follows:

    Authority: Secs. 1102, 1815, 1816, 1833, 1834 (a) and (h), 1842, 
1861(u), 1871, 1874, and 1875 of the Social Security Act (42 U.S.C. 
1302, 1395g, 1395h, 1395l, 1395m (a) and (h), 1395u, 1395x(u), 
1395hh, 1395kk, and 1395ll), and 42 U.S.C. 1395b-1.

    2. Section 421.5(d) is revised to read as follows:


Sec. 421.5  General provisions.

* * * * *
    (d) Nonrenewal of agreement or contract. Notwithstanding any of the 
provisions of this part, HCFA has the authority to nonrenew an 
agreement or contract when its term expires. An intermediary or carrier 
has the authority to nonrenew an agreement or contract when its term 
expires. The notice and hearing requirements for the termination of an 
agreement or contract set forth in Secs. 421.126, 421.128, and 421.205 
do not apply to such nonrenewal of an agreement or contract. An 
intermediary or carrier also has the authority to nonrenew an agreement 
or contract when its term expires.
* * * * *
    3. Section 421.100 is redesignated as Sec. 421.101 and revised to 
read as follows:


Sec. 421.101  Optional intermediary functions.

    An agreement between HCFA and an intermediary may specify the 
optional functions to be performed by the intermediary, which may 
include, but are not necessarily limited to, the following:
    (a) Provider audits. The intermediary must audit the records of 
providers of services as necessary to assure proper payments.
    (b) Utilization patterns. The intermediary must assist providers 
to--
    (1) Develop procedures relating to utilization practices;
    (2) Make studies of the effectiveness of those procedures and 
recommend methods to improve them;
    (3) Evaluate the results of utilization review activity; and
    (4) Assist in the application of safeguards against unnecessary 
utilization of services.
    (c) Resolution of cost report disputes. The intermediary must 
establish and maintain procedures approved by HCFA to consider and 
resolve any disputes that may result from provider dissatisfaction with 
an intermediary's determinations concerning provider cost reports.
    (d) Reconsideration of determinations. The intermediary must 
establish and maintain procedures approved by HCFA for the 
reconsideration of its determinations to deny payments to an individual 
or to the provider that furnished services to the individual. The PRO 
performs reconsideration of cases in which it made a determination 
subject to reconsideration.
    (e) Information and reports. The intermediary must furnish to HCFA 
any information and reports that HCFA requests in order to carry out 
its responsibilities in the administration of the Medicare program.
    (f) Other terms and conditions. The intermediary must comply with 
all applicable laws and regulations and with any other terms and 
conditions included in its agreement.
    (g) Dual intermediary responsibilities. With respect to the 
responsibility for service to provider-based HHAs and provider-based 
hospices, where the HHA or hospice and its parent provider will be 
served by different intermediaries under Sec. 421.117 of this part, the 
designated regional intermediary will process bills, make coverage 
determinations and make payments to the HHAs and hospices. The 
intermediary serving the parent provider will perform all fiscal 
functions, including audits and settlement of the Medicare cost reports 
and the HHA and hospice supplement worksheets.
    4. A new Sec. 421.100 is added to subpart B to read as follows:


Sec. 421.100  Required intermediary functions.

    An agreement between HCFA and an intermediary specifies the 
functions to be performed by the intermediary, which must include the 
following required functions and may include optional functions listed 
in Sec. 421.101 of this part and any others agreed to by HCFA. The 
required functions are:
    (a) Coverage. (1) The intermediary ensures that it makes payments 
only for services that are:
    (i) Furnished to Medicare beneficiaries;
    (ii) Covered under Medicare; and
    (iii) In accordance with PRO determinations when they are services 
for which the PRO has assumed review responsibility under its contract 
with HCFA.
    (2) The intermediary takes appropriate action to reject or adjust 
the claim if--
    (i) The intermediary or the PRO determines that the services 
furnished were not reasonable, not medically necessary, or not 
furnished in the most appropriate setting; or
    (ii) The intermediary determines that the claim does not properly 
reflect the kind and amount of services furnished.
    (b) Fiscal management.
    The intermediary must receive, disburse, and account for funds in 
making Medicare payments.
    5. Section 421.126 is amended by revising the heading and by adding 
a new paragraph (c) to read as follows:


Sec. 421.126  Termination or nonrenewal or agreements.

* * * * *
    (c) Nonrenewal by the intermediary or Secretary. (1) An 
intermediary may nonrenew an agreement with the Secretary by giving the 
Secretary written notice of the intermediary's intention to nonrenew 
the agreement at least 90 days before the end of the current period of 
the agreement.
    (2) The Secretary may nonrenew an agreement with an intermediary by 
giving the intermediary written notice of the Secretary's intention to 
nonrenew the agreement at least 90 days before the end of the current 
period of the agreement.
    (3) In the event that either the Secretary or intermediary gives 
notice of intention to nonrenew an agreement, the Secretary may extend 
the agreement for such time and under such conditions as may be 
specified in the agreement.
    (4) The providers served by an intermediary whose contract is not 
being renewed have the opportunity to nominate another intermediary, in 
accordance with Sec. 421.104.
    (5) The provisions for notice and the opportunity for a hearing in 
connection with the termination of an intermediary agreement, set forth 
in paragraph (b)(2) of this section and Sec. 421.128, do not apply to 
any nonrenewal of an intermediary agreement.
    6. Section 421.200 is amended by redesignating paragraphs (d) 
through (j) as (e) through (k), respectively. The introductory text is 
revised and a new paragraph (d) is added to read as follows:


Sec. 421.200  Carrier functions.

    A contract between HCFA and a carrier, other than a regional DMEPOS 
carrier, specifies the functions to be performed by the carrier, which 
may include, but are not necessarily limited to the following:
* * * * *
    (d) Payment on a fee schedule basis. If payment is on a fee 
schedule basis, the carrier must assure that payments are made in 
accordance with the applicable provisions of parts 414 and 415 of this 
chapter.
* * * * *
    7. Section 421.205 is revised to read as follows:


Sec. 421.205  Termination or nonrenewal of contracts.

    (a) Termination by the carrier. A carrier may terminate its 
contract at any time upon written notice to the Secretary of its 
intention to terminate. Upon notice to terminate, the contract 
continues for 180 days after such notice unless the Secretary decides 
to terminate at an earlier date.
    (b) Termination by the Secretary. (1) The Secretary may terminate a 
contract with a carrier at any time if he or she determines that the 
carrier has failed substantially to carry out any material terms of the 
contract or has performed its functions in a manner inconsistent with 
the effective and efficient administration of the Medicare Part B 
program.
    (2) Upon notification of the Secretary's intent to terminate the 
contract, the carrier may request a hearing within 20 days after the 
date of the notice of intent to terminate.
    (3) The hearing procedures will be those specified in 
Sec. 421.128(c).
    (c) Nonrenewal by the Secretary or carrier. (1) A carrier may 
nonrenew a contract with the Secretary by giving the Secretary written 
notice of its intention to nonrenew the contract at least 90 days 
before the end of the current period of the contract.
    (2) The Secretary may nonrenew a contract with a carrier by giving 
the carrier written notice of the Secretary's intention to nonrenew the 
contract at least 90 days before the end of the current period of the 
contract.
    (3) In the event that either the Secretary or the carrier gives 
notice of intention to nonrenew a contract for an additional period, 
the Secretary may extend the contract for such time and under such 
conditions as may be specified in the contract.
    (4) The provisions for notice and the opportunity for a hearing in 
connection with the termination of a carrier contract, set forth in 
paragraph (b) of this section and Sec. 421.128, do not apply to the 
nonrenewal of a carrier contract.

(Catalog of Federal Domestic Assistance Program No. 13.714, Medicare 
Assistance Program; 13.773, Medicare--Hospital Insurance Program; 
No. 93.774, Medicare-Supplemental Medical Insurance)

    Dated: August 5, 1993.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
    Dated: December 10, 1993.
Donna E. Shalala,
Secretary.
[FR Doc. 94-3608 Filed 02-18-94; 8:45 am]
BILLING CODE 4120-01-P