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Notes

42 C.F.R. §§ 412.505–412.511

5 sections in range

§412.505. Conditions for payment under the prospective payment system for long-term care hospitals.

42 C.F.R. § 412.505

(a)
Long-term care hospitals subject to the prospective payment system. To be eligible to receive payment under the prospective payment system specified in this subpart, a long-term care hospital must meet the criteria to be classified as a long-term care hospital set forth in § 412.23(e) for exclusion from the acute care hospital inpatient prospective payment systems specified in § 412.1(a)(1). This condition is subject to the special payment provisions of § 412.22(c), the provisions on change in hospital status of § 412.22(d), the provisions related to hospitals-within-hospitals under § 412.22(e), and the provisions related to satellite facilities under § 412.22(h).
(b)
General requirements.
(1)
Effective for cost reporting periods beginning on or after October 1, 2002, a long-term care hospital must meet the conditions for payment of this section, § 412.22(e)(3) and (h)(6), if applicable, and § 412.507 through § 412.511 to receive payment under the prospective payment system described in this subpart for inpatient hospital services furnished to Medicare beneficiaries.
(2)
If a long-term care hospital fails to comply fully with these conditions for payment with respect to inpatient hospital services furnished to one or more Medicare beneficiaries, CMS may withhold (in full or in part) or reduce Medicare payment to the hospital.
Notes, amendments, and revision history

Amendments

[67 FR 56049, Aug. 30, 2002, as amended at 71 FR 48140, Aug. 19, 2006]

Source

Source: 67 FR 56049, Aug. 30, 2002, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh.

Source

Source: 50 FR 12741, Mar. 29, 1985, unless otherwise noted.

Amendments

[67 FR 56049, Aug. 30, 2002, as amended at 71 FR 48140, Aug. 19, 2006]

§412.507. Limitation on charges to beneficiaries.

42 C.F.R. § 412.507

(a)
Prohibited charges. Except as provided in paragraph (b) of this section, a long-term care hospital may not charge a beneficiary for any covered services for which payment is made by Medicare, even if the hospital's costs of furnishing services to that beneficiary are greater than the amount the hospital is paid under the prospective payment system.
(1)
If Medicare has paid at the full LTCH prospective payment system standard Federal payment rate, that payment applies to the hospital's costs for services furnished until the high-cost outlier threshold is met.
(2)
If Medicare pays less than the full LTCH prospective payment system standard Federal payment rate and payment was not made at the site neutral payment rate (including, when applicable, the blended payment rate), that payment only applies to the hospital's costs for those costs or days used to calculate the Medicare payment.
(3)
For cost reporting periods beginning on or after October 1, 2016, for Medicare payments to a long-term care hospital described in § 412.23(e)(2)(ii), that payment only applies to the hospital's costs for those costs or days used to calculate the Medicare payment.
(4)
If Medicare has paid at the full site neutral payment rate, that payment applies to the hospital's costs for services furnished until the high-cost outlier is met.
(b)
Permitted charges.
(1)
A long-term care hospital that receives a payment at the full LTCH prospective payment system standard Federal payment rate or the site neutral payment rate may only charge the Medicare beneficiary for the applicable deductible and coinsurance amounts under §§ 409.82, 409.83, and 409.87 of this chapter, and for items and services as specified under § 489.20(a) of this chapter.
(2)
A long-term care hospital that receives a payment at less than the full LTCH prospective payment system standard Federal payment rate for a short-stay outlier case, in accordance with § 412.529 (which would not include any discharge paid at the site neutral payment rate), may only charge the Medicare beneficiary for the applicable deductible and coinsurance amounts under §§ 409.82, 409.83, and 409.87 of this chapter, for items and services as specified under § 489.20(a) of this chapter, and for services provided during the stay that were not the basis for the short-stay adjusted payment.
(3)
For cost reporting periods beginning on or after October 1, 2016, a long-term care hospital described in § 412.23(e)(2)(ii) may only charge the Medicare beneficiary for the applicable deductible and coinsurance amounts under §§ 409.82, 409.83, and 409.87 of this chapter, for items and services as specified under § 489.20(a) of this chapter, and for services provided during the stay for which benefit days were not available and that were not the basis for adjusted LTCH prospective payment system payment amount under § 412.526.
Notes, amendments, and revision history

Amendments

[80 FR 49767, Aug. 17, 2015, as amended at 81 FR 57268, Aug. 22, 2016]

Source

Source: 67 FR 56049, Aug. 30, 2002, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh.

Source

Source: 50 FR 12741, Mar. 29, 1985, unless otherwise noted.

Amendments

[80 FR 49767, Aug. 17, 2015, as amended at 81 FR 57268, Aug. 22, 2016]

§412.508. Medical review requirements.

42 C.F.R. § 412.508

(a)
Admission and quality review. A long-term care hospital must have an agreement with a QIO to have the QIO review, on an ongoing basis, the following:
(1)
The medical necessity, reasonableness, and appropriateness of hospital admissions and discharges.
(2)
The medical necessity, reasonableness, and appropriateness of inpatient hospital care for which additional payment is sought under the outlier provisions of §§ 412.523(d)(1) and 412.525(a).
(3)
The validity of the hospital's diagnostic and procedural information.
(4)
The completeness, adequacy, and quality of the services furnished in the hospital.
(5)
Other medical or other practices with respect to beneficiaries or billing for services furnished to beneficiaries.
(b)
Physician acknowledgement. Payment under the long-term care hospital prospective payment system is based in part on each patient's principal and secondary diagnoses and major procedures performed, as evidenced by the physician's entries in the patient's medical record. The hospital must assure that physicians complete an acknowledgement statement to this effect in accordance with paragraphs (b)(1) and (b)(2) of this section.
(1)
Content of physician acknowledgement statement. When a claim is submitted, the hospital must have on file a signed and dated acknowledgement from the attending physician that the physician has received the following notice:
(2)
Completion of acknowledgement. The acknowledgement must be completed by the physician at the time that the physician is granted admitting privileges at the hospital, or before or at the time the physician admits his or her first patient. Existing acknowledgements signed by physicians already on staff remain in effect as long as the physician has admitting privileges at the hospital.
(c)
Denial of payment as a result of admissions and quality review.
(1)
If CMS determines, on the basis of information supplied by a QIO, that a hospital has misrepresented admissions, discharges, or billing information, or has taken an action that results in the unnecessary admission or unnecessary multiple admissions of an individual entitled to benefits under Part A, or other inappropriate medical or other practices with respect to beneficiaries or billing for services furnished to beneficiaries, CMS may, as appropriate—
(i)
Deny payment (in whole or in part) under Part A with respect to inpatient hospital services provided for an unnecessary admission or subsequent readmission of an individual; or
(ii)
Require the hospital to take other corrective action necessary to prevent or correct the inappropriate practice.
(2)
When payment with respect to admission of an individual patient is denied by a QIO under paragraph (c)(1) of this section, and liability is not waived in accordance with §§ 411.400 through 411.402 of this chapter, notice and appeals are provided under procedures established by CMS to implement the provisions of section 1155 of the Act, Right to Hearing and Judicial Review.
(3)
A determination under paragraph (c)(1) of this section, if it is related to a pattern of inappropriate admissions and billing practices that has the effect of circumventing the prospective payment system, is referred to the Department's Office of Inspector General for handling in accordance with § 1001.201 of this title.
Notes, amendments, and revision history

Amendments

[67 FR 56049, Aug. 30, 2002, as amended at 71 FR 48140, Aug. 19, 2006]

Source

Source: 67 FR 56049, Aug. 30, 2002, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh.

Source

Source: 50 FR 12741, Mar. 29, 1985, unless otherwise noted.

Amendments

[67 FR 56049, Aug. 30, 2002, as amended at 71 FR 48140, Aug. 19, 2006]

§412.509. Furnishing of inpatient hospital services directly or under arrangement.

42 C.F.R. § 412.509

(a)
Subject to the provisions of § 412.521(b), the applicable payments made under this subpart are payment in full for all inpatient hospital services, as defined in § 409.10 of this chapter. Inpatient hospital services do not include the following:
(1)
Physicians' services that meet the requirements of § 415.102(a) of this subchapter for payment on a fee schedule basis.
(2)
Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act.
(3)
Nurse practitioners and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.
(4)
Certified nurse midwife services, as defined in section 1861(gg) of the Act.
(5)
Qualified psychologist services, as defined in section 1861(ii) of the Act.
(6)
Services of an anesthetist, as defined in § 410.69 of this subchapter.
(b)
Medicare does not pay any provider or supplier other than the long-term care hospital for services furnished to a Medicare beneficiary who is an inpatient of the hospital except for services described in paragraphs (a)(1) through (a)(6) of this section.
(c)
The long-term care hospital must furnish all necessary covered services to the Medicare beneficiary who is an inpatient of the hospital either directly or under arrangements (as defined in § 409.3 of this subchapter).
Notes, amendments, and revision history

Source

Source: 67 FR 56049, Aug. 30, 2002, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh.

Source

Source: 50 FR 12741, Mar. 29, 1985, unless otherwise noted.

§412.511. Reporting and recordkeeping requirements.

42 C.F.R. § 412.511

A long-term care hospital participating in the prospective payment system under this subpart must meet the requirement of §§ 412.22(e)(3) and 412.22(h)(6) to report co-located status, if applicable, and the recordkeeping and cost reporting requirements of §§ 413.20 and 413.24 of this subchapter.
Notes, amendments, and revision history

Amendments

[71 FR 48140, Aug. 18, 2006]

Source

Source: 67 FR 56049, Aug. 30, 2002, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh.

Source

Source: 50 FR 12741, Mar. 29, 1985, unless otherwise noted.

Amendments

[71 FR 48140, Aug. 18, 2006]