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Duplicate Medicare Professional Fee Billing by Both the Critical Access Hospital and the Health Care Practitioner to Medicare Part B

Under Section 1834(g)(1) of the Social Security Act and Federal regulations (42 CFR §§ 410.152(k) and 413.70(b)), Critical Access Hospitals (CAHs) are paid under the Standard Payment Method unless they elect to be paid under the Optional (Elective) Payment Method. Under Section 1834(g)(2) of the Social Security Act and Federal regulation (42 CFR § 413.70(b)(3)(i)), a CAH may elect the Optional (Elective) Payment Method, under which it bills the Part B Medicare Administrative Contractor (MAC) for both Medicare Part B facility services and Medicare Part B professional services for its outpatients. If a physician or other practitioner reassigns his or her Medicare Part B billing rights pursuant to 42 CFR part 424, subpart F, and agrees to be included under a CAH's Optional (Elective) Payment Method, he or she must not bill the MAC for any outpatient professional services furnished at the CAH once the reassignment becomes effective. The CAH must forward a copy of the completed assignment form (Form CMS 855R) to the MAC and keep the original form on file. Each practitioner must sign an attestation that clearly states that he or she will not bill Medicare Part B for any services furnished in the CAH outpatient department once the reassignment has been given to the CAH (Medicare Claims Processing Manual, Chapter 4, Section 250.2). We will determine whether CAHs forwarded a completed Form CMS 855R to the MAC. We will determine whether both the CAH and physician billed and were paid by the MAC for the same outpatient professional services. We will determine whether the beneficiary paid coinsurance amounts to both the CAH and physician or other practitioner. We will also determine whether CMS has an edit in place to ensure that duplicate payments for beneficiary outpatient professional services are not made.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
April 2021 Centers for Medicare & Medicaid Services Duplicate Medicare Professional Fee Billing by Both the Critical Access Hospital and the Health Care Practitioner to Medicare Part B Office of Audit Services W-00-21-35869 2022