Medicare program; criteria and standards for evaluating intermediary and carrier performance during FY 1995--HCFA. General notice with comment period

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning October 1, 1994. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract or takes other contract actions (for example, assigning or reassigning providers of services to an intermediary or designating regional or national intermediaries). This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act. We are publishing for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.     

Criteria and standards for evaluating intermediary and carrier performance--HCFA. General notice with comment period

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning October 1, 1990. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract or takes other contract actions; assigns or reassigns providers of services to an intermediary; or designates regional or national intermediaries. This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act, which requires us to publish for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.     

Criteria and standards for evaluating intermediary and carrier performance--HCFA. General notice with comment period

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning June 1, 1990. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary or carrier agreement or takes other contract actions; assigns or reassigns providers of services to an intermediary; or designates regional or national intermediaries. This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act, which requires us to publish for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.     

Medicare program; criteria and standards for evaluating intermediary and carrier performance during FY 1994--HCFA. General notice with comment period

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning October 1, 1993. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract or takes other contract actions (for example, assigning or reassigning providers of services to an intermediary, or designating regional or national intermediaries). This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act. We are publishing for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.     

Medicare program; criteria and standards for evaluating intermediary and carrier performance during FY 1993--HCFA. General notice with comment period

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning October 1, 1992. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract or takes other contract actions (e.g., assigning or reassigning providers of services to an intermediary, designating regional or national intermediaries, etc.). This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act. We are publishing for public comment in the Federal Register those criteria and standards against which we evaluate intermediaries and carriers.     

Medicare program; criteria and standards for evaluating intermediary and carrier performance--HCFA. General notice with comment period

This notice describes the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program beginning October 1, 1991. The results of these evaluations are considered whenever HCFA enters into, renews, or terminates an intermediary agreement or carrier contract or takes other contract actions (e.g., assigning or reassigning providers of services to an intermediary; or designating regional or national intermediaries, etc.). This notice is published in accordance with sections 1816(f) and 1842(b)(2) of the Social Security Act, which require us to publish for public comment in the Federal Register whose criteria and standards against which we evaluate intermediaries and carriers.     

Medicare program; criteria and standards for evaluating intermediary and carrier performance: millennium compliance--HCFA. General notice with comment period

This notice revises the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program. This revision establishes a performance standard requiring these contractors to meet requirements for millennium compliance. We require contractors to certify that they have made all necessary system(s) changes and have tested those systems in accordance with HCFA guidelines.     

Medicare program; criteria and standards for evaluating common working file hosts--HCFA. General notice with comment period

This notice describes the criteria and standards to be used for evaluating the performance of Common Working File (CWF) hosts in the administration of the Medicare program, for the current evaluation period beginning June 1, 1991. The results of these evaluations will be considered whenever the Health Care Financing Administration enters into, renews/extends, or terminates a Medicare carrier contract which provides for the performance of CWF host services. Since these services are currently performed by Medicare carriers, this notice is published in accordance with section 1842(b)(2) of the Social Security Act which requires us to publish for public comment those criteria and standards against which we evaluate Medicare carriers.     

Medicare program: data, standards and methodology used to establish fiscal year 1993 budgets for fiscal intermediaries and carriers--HCFA. Final notice

This notice is published in accordance with sections 1816(c)(1) and 1842(c)(1) of the Social Security Act which requires us to publish the final data, standards and methodology used to establish budgets for Medicare intermediaries and carriers. It announces that we are adopting as final, and responds to comments about, the data, standards, and methodology we proposed to use to establish Medicare fiscal intermediary and carrier budgets for the fiscal year (FY) 1993, beginning October 1, 1992.     

Medicare program; carrier jurisdiction for claims for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) and other issues involving suppliers, and criteria and standards for evaluating regional DMEPOS carriers--HCFA. Final rule with comment period

This final rule Modifies regulations to provide that claims for durable medical equipment, prosthetics, orthotics and certain other items covered under part B of Medicare be processed by designated carriers. Specifies the jurisdictions each designated carrier will serve. Changes the method by which claims for these items are allocated among the carriers from "point of sale" to "beneficiary residence." Establishes certain minimum standards for suppliers for purposes of submitting the above claims. Incorporates in regulations certain supplier disclosure requirements imposed under section 4164 of the Omnibus Budget Reconciliation Act of 1990, as part of the process for issuing and renewing a supplier's billing number. Describes the criteria and standards to be used beginning October 1, 1993 for evaluating the performance of designated carriers processing claims for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) in the administration of the Medicare program. Section 1842(b)(2) of the Social Security Act requires us to publish criteria and standards against which we evaluate Medicare carriers for public comment in the Federal Register. We expect the above changes to lead to more efficient and economical administration of the Medicare program.     

Medicare program; data, standards and methodology used to establish fiscal year 1992 budgets for fiscal intermediaries and carriers--HCFA. Final notice

This notice is published in accordance with sections 1816(c)(1) and 1842(c)(1) of the Social Security Act which require us to publish the final data, standards and methodology used to establish budgets for Medicare intermediaries and carriers. It announces that we are adopting as final without revision proposed data, standards, and methodology used to establish Medicare fiscal intermediary and carrier budgets for the fiscal year (FY) 1992, beginning October 1, 1991. It also contains our response to public comments on the proposal.     

Medicare program: data, standards, and methodology used to establish fiscal year 1994 budgets for fiscal intermediaries and carriers--HCFA. Final notice

This notice is published in accordance with sections 1816(c)(1) and 1842(c)(1) of the Social Security Act which require us to publish the final data, standards, and methodology used to establish budgets for Medicare intermediaries and carriers. In this notice, we respond to the comments received in response to our notice of October 5, 1993 and we announce the adoption of the proposed data, standards, and methodology that we used to establish the Medicare fiscal intermediary and carrier budgets for fiscal year (FY) 1994, beginning October 1, 1993, as final and without revision.     

Medicare program; "without fault" and waiver of recovery from an individual as it applies to Medicare overpayment liability--HCFA. Proposed rule

This rule would amend the Medicare regulations governing liability for overpayments to eliminate application of certain regulations of the Social Security Administration and to replace them with HCFA regulations more specific to circumstances involving Medicare overpayments. The following specific changes are included in this rule. Explicit criteria and the circumstances under which a provider or supplier can be relieved of liability for an overpayment on the basis of being "without fault" with respect to the overpayment. Specific criteria and circumstances of the conditions under which a waiver of recovery for Medicare overpayments would apply to individuals. A provision to ordinarily consider it inequitable to recover an overpayment from a without-fault individual when an overpayment is made to a without-fault provider. Specific provisions that enable Medicare intermediaries and carriers to determine without fault in Medicare overpayments resulting from Medicare secondary payer conditional payments. Provisions that grant Peer Review Organizations the authority to make without-fault determinations. Provisions for an administrative appeals process for providers and suppliers with regard to a "not-without-fault" determination. We expect this rule would prevent some providers and suppliers from claiming without-fault status. This could reduce the number of overpayment liabilities passed on to individuals and result in a slight increase in the amount of money recovered.     

Medicare program; provider reimbursement determinations and appeals. Final rule

Subpart R of 42 CFR part 405 consists of regulations governing Medicare reimbursement determinations, and appeals of those determinations, by health care providers. (For the sake of simplicity, throughout this final rule, we use "reimbursement" to refer to Medicare payment under both the reasonable cost and prospective payment systems.) Under section 1878 of the Social Security Act (the Act) and the subpart R regulations, the Provider Reimbursement Review Board (the Board) has the authority to adjudicate certain substantial reimbursement disputes between providers and fiscal intermediaries (intermediaries). Board decisions are subject to review by the CMS Administrator, and the final agency decision of the Board or the Administrator, as applicable, is reviewable in Federal district court. In addition, under the subpart R regulations, intermediaries have the authority to hold hearings and adjudicate certain other payment and reimbursement disputes with providers. This final rule updates, clarifies, and revises various provisions of the regulations governing provider reimbursement determinations, appeals before the Board, appeals before the intermediaries (for lesser disputes), and Administrator review of decisions made by the Board.     

Medicare program; Medicare integrity program, intermediary and carrier functions, and conflict of interest requirements--HCFA. Proposed rule

This proposed rule would implement section 1893 of the Social Security Act (the Act) by establishing the Medicare integrity program (MIP) to carry out Medicare program integrity activities that are funded from the Medicare Trust Funds. Section 1893 expands our contracting authority to allow us to contract with "eligible entities" to perform Medicare program integrity activities. These activities include review of provider and supplier activities, including medical, fraud, and utilization review: cost report audits; Medicare secondary payer determinations; education of providers, suppliers, beneficiaries, and other persons regarding payment integrity and benefit quality assurance issues; and developing and updating a list of durable medical equipment items that are subject to prior authorization. This proposed rule would set forth the definition of eligible entities, services to be procured, competitive requirements based on Federal acquisition regulations and exceptions (guidelines for automatic renewal), procedures for identification, evaluation, and resolution of conflicts of interest, and limitations on contractor liability. In addition, this proposed rule would bring certain sections of the Medicare regulations concerning fiscal intermediaries and carriers into conformity with the Act. The rule would distinguish between those functions that the statute requires be included in agreements with intermediaries and those that may be included in the agreements. It would also provide that some or all of the listed functions may be included in carrier contracts. Currently all these functions are mandatory for carrier contracts. These changes would give us the flexibility to transfer functions from one intermediary or carrier to another or to otherwise limit the functions an intermediary or carrier performs if we determine that to do so would result in more effective and efficient program administration.     

Medicare program; criteria and standards for evaluating intermediary and carrier performance during FY 1994--HCFA. General notice

In the September 30, 1993 issue of the Federal Register, we published a general notice with comment period describing the criteria and standards for evaluating intermediary and carrier performance in administering the Medicare program during FY 1994. This notice amends that document to require that contractors certify the accuracy and completeness of the information submitted to HCFA with respect to the evaluation process.     

Medicare program; waiver requirements and solvency standards for provider-sponsored organizations--HCFA. Interim final rule with comment period

This interim final rule with a request for comments implements authority to waive, in the case of provider-sponsored organizations (PSOs) that meet certain criteria, the requirement that Medicare + Choice organizations be licensed by a State as risk-bearing entities. The waivers will be approved only under certain conditions where the State has denied or failed to act on an application for licensure. This rule also establishes solvency standards that certain entities must meet to contract as PSOs under the new Medicare + Choice program. These standards apply to PSOs that have received a waiver of the requirement that Medicare + Choice organizations be licensed by a State as risk-bearing entities.     

Medicare program; end-stage renal disease (ESRD) payment exception requests and organ procurement costs--HCFA. Final rule

These final regulations specify the criteria HCFA uses to determine if a facility that furnished dialysis services to Medicare patients with end-stage renal disease (ESRD) qualifies for a higher payment under an exception to its prospectively determined payment rate and the procedures HCFA uses to evaluate ESRD payment exception requests. These regulations also revise the way HCFA computes acquisition costs for organs that are transplanted into Medicare beneficiaries.     

Medicare and Medicaid programs; salary equivalency guidelines for physical therapy, respiratory therapy, speech language pathology, and occupational therapy services--HCFA. Final rule

This final rule sets forth revisions to the salary equivalency guidelines for Medicare payment for the reasonable costs of physical therapy and respiratory therapy services furnished under arrangements by an outside contractor. This final rule also sets forth new salary equivalency guidelines for Medicare payment for the reasonable costs of speech language pathology and occupational therapy services furnished under arrangements by an outside contractor. The guidelines do not apply to inpatient hospital services and hospice services. The guidelines will be used by Medicare fiscal intermediaries to determine the maximum allowable cost of those services.     

Medicare program; intermediary and carrier checks that are lost, stolen, defaced, mutilated, destroyed or paid on forged endorsements--HCFA. Final rule with comment period

This rule revises the Medicare regulations governing the procedures for replacing checks issued by our fiscal intermediaries and carriers that are lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsements. Each State already has an established legal process for pursuing a claim for recovery of the amount of a check paid on a forged endorsement, and it is inefficient and ineffective to provide duplicative Federal requirements. These regulations stipulate that any replacement or reclamation proceedings will be carried out in accordance with the applicable State law and that a replacement check will not be issued until Medicare has made recovery on the proceeds of the original check. However, we will continue to reissue checks that have not been negotiated.