Medicare Physician Regulation Relief Amendments of 1990

Medicare Physician Regulation Relief Amendments of 1990 - Amends title XVIII (Medicare) of the Social Security Act to require carriers and peer review organizations to release the medical review screen or the associated screening parameter to a physician before notifying such physician that payment for his or her service has been denied.

Permits Medicare reimbursement of a patient's regular physician for services provided to such patient by another physician who occasionally covers for the regular physician.

Requires Medicare carriers to provide physicians, upon request and without charge, with carrier-generated information which physicians need to submit a payment claim or respond to a carrier inquiry.

Allows a medical society or other professional organization representing physicians to represent a group or class of physicians in Medicare payment determinations, reconsiderations, or appeals.

Directs the Secretary of Health and Human Services to appoint, based on nominations submitted by national medical organizations representing physicians, a Practicing Physicians Advisory Council with which the Secretary must consult concerning changes in the Medicare program and proposed changes in regulations and carrier operation policies.

 
HR 4475 IH
101st CONGRESS
2d Session
 H. R. 4475
To amend title XVIII of the Social Security Act to provide relief from
certain medicare regulations relating to physicians' services.
IN THE HOUSE OF REPRESENTATIVES
April 4, 1990
Mr. ROWLAND of Georgia (for himself, Mr. TAUKE, Mr. DERRICK, Mr. BLILEY,
Mr. THOMAS of Georgia, Mr. LEWIS of California, Mr. SOLOMON, Mr. FAZIO,
Mr. SMITH of New Hampshire, Mr. BROWN of California, Ms. PATTERSON, Mr. YOUNG
of Alaska, Mr. MATSUI, Mr. SARPALIUS, Mr. KOLTER, Mr. MURPHY, Mr. TOWNS,
and Mr. YOUNG of Florida) introduced the following bill; which was referred
jointly to the Committees on Ways and Means and Energy and Commerce
A BILL
To amend title XVIII of the Social Security Act to provide relief from
certain medicare regulations relating to physicians' services.
  Be it enacted by the Senate and House of Representatives of the United
  States of America in Congress assembled,
SECTION 1. SHORT TITLE.
  This Act may be cited as the `Medicare Physician Regulation Relief Amendments
  of 1990'.
SEC. 2. RELEASE OF INFORMATION BEFORE NOTICE OF DENIAL OF PAYMENT.
  (a) IN GENERAL- Section 1842(l)(2) of the Social Security Act (42
  U.S.C. 1395u(l)(2) is amended by adding at the end the following: `Before
  sending such denial notice to a physician or individual, the carrier or
  organization must release to the physician the medical review screen or
  the associated screening parameter describing the criteria upon which the
  denial of payment may be made.'.
  (b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply to
  notices of denial sent after the date of the enactment of this Act.
SEC. 3. FLEXIBILITY IN BILLING ARRANGEMENTS IN CASES OF CERTAIN PHYSICIANS
`COVERING' FOR OTHER PHYSICIANS ON AN OCCASIONAL BASIS.
  (a) PURPOSE- The purpose of the amendments made by this section is to
  permit physicians in solo practice and those in another group practice to
  `cover' medicare patients for each other and to make it possible for the
  personal physicians of such patients to bill and receive reimbursement
  for professional services rendered by their colleagues who `cover' for them.
  (b) IN GENERAL- The first sentence of section 1842(b)(6) of the Social
  Security Act (42 U.S.C. 1395u(b)(6)) is amended--
  (1) by striking `and' before `(C)', and
  (2) by inserting before the end the following: `, and (D) payment may
  be made to a physician who arranges for services to be provided to an
  individual by a second physician on an occasional basis in situations
  where (i) the first physician is unavailable to provide such services,
  (ii) the individual has arranged to receive medical care services from
  the first physician, and (iii) the claim form submitted to the carrier
  indicates that the claim is for such `covered' services'.
  (c) EFFECTIVE DATE- The amendments made by subsection (b) shall be effective
  for services provided on or after the date of the enactment of this Act.
SEC. 4. RELEASE OF CERTAIN CARRIER INFORMATION WITHOUT CHARGE.
  (a) IN GENERAL- Section 1842(b)(3) of the Social Security Act (42
  U.S.C. 1395u(b)(3)) is amended--
  (1) by adding `and' at the end of subparagraph (L), and
  (2) by inserting after subparagraph (L) the following new subparagraph:
  `(M) will provide physicians, upon request and without charge, with
  carrier-generated information (including the identifier number or other
  code of a referring physician, a list of maximum allowable charges, and
  coding protocols) needed by physicians to submit a claim for payment or
  to respond to a carrier inquiry under this part;'.
  (b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply to
  information provided on or after the date of the enactment of this Act.
SEC. 5. MEDICAL SOCIETY REPRESENTATION OF PHYSICIANS IN APPEALS.
  Section 1869 of the Social Security Act (42 U.S.C. 1395ff) is amended by
  adding at the end the following new subsection:
  `(c) Notwithstanding any provision of law regarding standing, a medical
  society or other professional organization representing physicians
  may represent a group or class of physicians as to determinations,
  reconsiderations, or appeals under this section.'.
SEC. 6. PRACTICING PHYSICIANS ADVISORY COUNCIL.
  Title XVIII of the Social Security Act is amended by inserting after
  section 1876 the following new section:
`PRACTICING PHYSICIANS ADVISORY COUNCIL
  `SEC. 1877. (a) The Secretary shall appoint, based upon nominations
  submitted by national medical organizations representing physicians,
  a Practicing Physicians Advisory Council (in this section referred to
  as the `Council') to be composed of 15 physicians, each of whom has
  submitted at least 250 claims for physicians' services under this title
  in the previous year. At least 11 of the members of the Council shall be
  physicians described in section 1861(r)(1) and the members of the Council
  shall include both participating and nonparticipating physicians.
  `(b) The Secretary shall consult with the Council concerning--
  `(1) changes in the scope of coverage, benefits, and operation of the
  program under this title, and
  `(2) proposed changes in regulations and carrier operation policies
  (including carrier manuals, instructions, letters, and other forms of
  policies).
  `(c) The Council shall meet at least 6 times each year.
  `(d) Members of the Council shall be entitled to receive reimbursement of
  expenses and per diem in lieu of subsistence in the same manner as other
  members of advisory councils appointed by the Secretary are provided such
  reimbursement and per diem under this title.'.