United States Government Publishing Office publisher pbl distributor dst United States National Archives and Records Administration Office of the Federal Register author aut Government Organization text government publication eng FR Regulatory Information 1998_register executive 2010-09-24 article Proposed Rules D09002ee1be006e83 D09002ee1be006f65 United States Department of Health and Human Services originator org United States Government Agency or Subagency United States Health Care Financing Administration originator org United States Government Agency or Subagency This proposed rule would incorporate into regulations the provisions of sections 1877 and 1903(s) of the Social Security Act. Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services under the Medicare program, unless certain exceptions apply. The following services are designated health services: <bullet> Clinical laboratory services. <bullet> Physical therapy services. <bullet> Occupational therapy services. <bullet> Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services. <bullet> Radiation therapy services and supplies. <bullet> Durable medical equipment and supplies. <bullet> Parenteral and enteral nutrients, equipment, and supplies. <bullet> Prosthetics, orthotics, and prosthetic devices and supplies. <bullet> Home health services. <bullet> Outpatient prescription drugs. <bullet> Inpatient and outpatient hospital services. In addition, section 1877 provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for designated health services furnished under a prohibited referral, nor may the Secretary make payment for a designated health service furnished under a prohibited referral. Section 1903(s) of the Social Security Act extended aspects of the referral prohibition to the Medicaid program. It denies payment under the Medicaid program to a State for certain expenditures for designated health services. Payment would be denied if the services are furnished to an individual on the basis of a physician referral that would result in the denial of payment for the services under Medicare if Medicare covered the services to the same extent and under the same terms and conditions as under the State plan. This proposed rule incorporates these statutory provisions into the Medicare and Medicaid regulations and interprets certain aspects of the law. The proposed rule is based on the provisions of section 1903(s) and section 1877 of the Social Security Act, as amended by section 13562 of the Omnibus Budget Reconciliation Act of 1993, and by section 152 of the Social Security Act Amendments of 1994. 63 FR 1659 https://www.govinfo.gov/app/details/FR-1998-01-09/98-282 98-282 fr09ja98-24 RIN 0938-AG80 4120-03-P HCFA-1809-P https://www.govinfo.gov/app/details/FR-1998-01-09/98-282 https://www.govinfo.gov/content/pkg/FR-1998-01-09/html/98-282.htm https://www.govinfo.gov/content/pkg/FR-1998-01-09/pdf/98-282.pdf 70 p. 1659 1728 63 FR 1659 Title 42 Part 411 42 CFR Part 411 Title 42 Part 424 42 CFR Part 424 Title 42 Part 435 42 CFR Part 435 Title 42 Part 455 42 CFR Part 455 RIN 0938-AG80 Medicare and Medicaid Programs; Physicians' Referrals to Health Care Entities With Which They Have Financial Relationships; Federal Register Vol. 63, Issue PRORULE 98-282 DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Care Financing Administration 1995-08-14 HCFA-1809-P 4120-03-P 98-282 Proposed rule.

This proposed rule would incorporate into regulations the provisions of sections 1877 and 1903(s) of the Social Security Act. Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services under the Medicare program, unless certain exceptions apply. The following services are designated health services: <bullet> Clinical laboratory services. <bullet> Physical therapy services. <bullet> Occupational therapy services. <bullet> Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services. <bullet> Radiation therapy services and supplies. <bullet> Durable medical equipment and supplies. <bullet> Parenteral and enteral nutrients, equipment, and supplies. <bullet> Prosthetics, orthotics, and prosthetic devices and supplies. <bullet> Home health services. <bullet> Outpatient prescription drugs. <bullet> Inpatient and outpatient hospital services. In addition, section 1877 provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for designated health services furnished under a prohibited referral, nor may the Secretary make payment for a designated health service furnished under a prohibited referral. Section 1903(s) of the Social Security Act extended aspects of the referral prohibition to the Medicaid program. It denies payment under the Medicaid program to a State for certain expenditures for designated health services. Payment would be denied if the services are furnished to an individual on the basis of a physician referral that would result in the denial of payment for the services under Medicare if Medicare covered the services to the same extent and under the same terms and conditions as under the State plan. This proposed rule incorporates these statutory provisions into the Medicare and Medicaid regulations and interprets certain aspects of the law. The proposed rule is based on the provisions of section 1903(s) and section 1877 of the Social Security Act, as amended by section 13562 of the Omnibus Budget Reconciliation Act of 1993, and by section 152 of the Social Security Act Amendments of 1994.

Comments will be considered if we receive them at the appropriate address, as provided below, no later than 5 p.m. on March 10, 1998. We will also consider comments that we received in response to the final rule with comment period, ``Physician Financial Relationships With, and Referrals to, Health Care Entities That Furnish Clinical Laboratory Services and Financial Relationship Reporting Requirements,'' which we published in the Federal Register on August 14, 1995 (60 FR 41914). Joanne Sinsheimer (410) 786-4620. Vol. 63, no. 6 Office of the Federal Register, National Archives and Records Administration 1998-01-09 continuing daily deposited born digital 422 p. Table of Contents: AE 2.7: GS 4.107: AE 2.106: KF70.A2 https://www.govinfo.gov/app/details/FR-1998-01-09 P0b002ee180a56a40 0097-6326 0042-1219 0364-1406 769-004-00000-9 000582072 f:fr09ja98 https://www.govinfo.gov/app/details/FR-1998-01-09 https://www.govinfo.gov/content/pkg/FR-1998-01-09/pdf/FR-1998-01-09.pdf fdlp 1321 1733 DGPO 2010-09-24 2023-05-06 FR-1998-01-09 machine generated eng FR FR-1998-01-09 63 6