Medicare Physician Regulatory Relief Amendments of 1991

Medicare Physician Regulatory Relief Amendments of 1991 - Amends title XVIII (Medicare) of the Social Security Act to: (1) prohibit the denial of physician claims because of patient failure to complete Medicare secondary payer questionnaires; (2) prohibit carriers from using extrapolation to recover the amounts they reimbursed physicians for claims for which Medicare disallows payment, if the physician requests that each such claim be individually identified; (3) prohibit the imposition of specified user fees on physicians; (4) require consideration of physician comments in annual carrier performance reviews; (5) allow individuals (including physicians) to file administrative appeals when they have suffered damages as a result of the failure of a carrier to carry out Medicare policies; and (6) require review of medical necessity denials by physicians in the same medical specialty as the physician providing the service.

Amends the Medicare and Medicaid (title XIX of the Social Security Act) programs to permit the reimbursement of a patient's regular physician for services provided by another physician who covers for the regular physician under contractual arrangements.

Amends title XI of the Social Security Act to repeal the peer review requirement for certain surgical procedures.

 
HR 2695 IH
102d CONGRESS
1st Session
 H. R. 2695
To amend title XVIII of the Social Security Act to provide relief to physicians
with respect to excessive regulations under the medicare program.
IN THE HOUSE OF REPRESENTATIVES
June 19, 1991
Mr. ROWLAND (for himself, Mr. BLILEY, Mr. FAZIO, Mr. THOMAS of Wyoming,
Mr. ALLARD, Mr. TAYLOR of Mississippi, Mr. RAY, Mr. DARDEN, Mr. JONES of
Georgia, Mr. JENKINS, Mr. THOMAS of Georgia, Mr. MOORHEAD, and Mr. HALL of
Texas) 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 to physicians
with respect to excessive regulations under the medicare program.
  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 Regulatory Relief Amendments
  of 1991'.
SEC. 2. NO MEDICARE SECONDARY PAYOR DENIAL BASED ON FAILURE TO COMPLETE
QUESTIONNAIRE.
  Section 1862(b)(2) of the Social Security Act (42 U.S.C. 1395y(b)(2))
  is amended by adding at the end the following new subparagraph:
  `(C) TREATMENT OF QUESTIONNAIRES- The Secretary shall not fail to make
  payment under subparagraph (A) based upon the failure of an individual to
  complete a questionnaire concerning the existence of a primary plan. However,
  any such payment remains conditional (as provided under subparagraph (B)).'.
SEC. 3. LIMITATIONS ON USE OF EXTRAPOLATION.
  Section 1842(c) of the Social Security Act (42 U.S.C. 1395u(c)) is amended
  by adding at the end the following new paragraph:
  `(4) In carrying out its contract under subsection (b)(3) with respect to
  physicians' services--
  `(A) the carrier may use extrapolation in order to identify claims for
  which payment may be disallowed;
  `(B) the carrier may not recoup or offset payment amounts based on
  extrapolation if the physician requests that disallowed claims be identified
  individually; and
  `(C) no refund, offset assessment, penalties, or interest shall accrue with
  respect to a claim that is disallowed until the date the administrative
  appeals process has been completed.'.
SEC. 4. LIMITATION ON CARRIER USER FEES.
  Section 1842(c) of the Social Security Act (42 U.S.C. 1395u(c)) is further
  amended by adding at the end the following new paragraph:
  `(5) Neither a carrier nor the Secretary may impose a fee under this title--
  `(A) for the filing of a claim on paper relating to physicians' services,
  `(B) for an error in filing a claim relating to physicians' services or
  for such a claim which is denied,
  `(C) for any appeal under this title with respect to physicians' services,
  `(D) for applying for (or obtaining) a unique identifier under subsection
  (r), or
  `(E) for responding to inquiries respecting physicians' services or for
  providing information with respect to medical review of such services.'.
SEC. 5. INCLUDING PHYSICIAN INPUT IN ANNUAL CARRIER PERFORMANCE REVIEWS.
  Section 1842(b)(2) of the Social Security Act (42 U.S.C. 1395u(b)(2))
  is amended--
  (1) in the second sentence of subparagraph (A), by inserting `(including
  the reduction of administrative burdens on physicians furnishing services
  for which payment is made under this part)' after `contract obligations
  under this section', and
  (2) by adding at the end the following new subparagraph:
  `(D) In applying the standards and criteria established under subparagraph
  (A), the Secretary shall consider any evaluations (with respect to such
  standards and criteria) submitted by medical societies representing
  physicians who are served by the carrier.'.
SEC. 6. APPEALS OF CARRIER VIOLATIONS.
  Section 1842(b)(2) of the Social Security Act (42 U.S.C. 1395u(b)(2))
  is further amended by adding at the end the following new subparagraph:
  `(E) The Secretary shall provide that any individual (including a physician)
  who--
  `(i) is aggrieved by the failure of a carrier to carry out policies
  established under this part, whether established through the carrier
  manual, regional office transmittals, central office transmittals, or
  other means, and
  `(ii) establishes that the individual has (or, in the case of a failure
  affecting more than one individual, the individuals affected by the failure
  have) suffered damages aggregating at least $500 as a result of the failure,
may obtain a hearing before the Secretary respecting such failure. If a
carrier is found to have such a failure, the Secretary shall order the
carrier to compensate the aggrieved individuals for such failure.'.
SEC. 7. REVIEW OF MEDICAL NECESSITY DENIALS BY PHYSICIANS IN SAME SPECIALTY.
  Section 1842(b)(2) of the Social Security Act (42 U.S.C. 1395u(b)(2))
  is further amended by adding at the end the following new subparagraph:
  `(F) In the contract under subsection (c), the Secretary shall require
  each carrier, in the case of a decision to deny payment for physicians'
  services under section 1862(a)(1), to provide for review of the decision
  by a physician in the same medical specialty as the medical specialty of
  the physician who provided the services.'.
SEC. 8. CLARIFICATION OF PERMISSIBLE SUBSTITUTE BILLING ARRANGEMENTS FOR
PHYSICIANS' SERVICES UNDER THE MEDICARE AND MEDICAID PROGRAMS.
  (a) MEDICARE PROGRAM-
  (1) IN GENERAL- Clause (D) of section 1842(b)(6) of the Social Security
  Act (42 U.S.C. 1395u(b)(6)), as inserted by section 4110(a)(2) of the
  Omnibus Budget Reconciliation Act of 1990, is amended to read as follows:
  `(D)(i) payment may be made to a physician for physicians' services (and
  services incident to such services) to be provided by a second physician on
  a reciprocal basis to individuals who are patients of the first physician
  if (I) the first physician is unavailable to provide the services, (II)
  the services are not provided by the second physician over a continuous
  period of longer than 60 days, and (III) the claim form submitted to the
  carrier includes the second physician's unique identifier (provided under
  the system established under subsection (r)) and indicates that the claim
  meets the requirements of this clause for payment to the first physician;
  and (ii) payment may be made to a physician for physicians' services
  (and services incident to such services) which that physician pays a
  second physician on a per diem or other fee-for-time basis to provide
  to individuals who are patients of the first physician if (I) the first
  physician is unavailable to provide the services, (II) the services are not
  provided by the second physician over a continuous period of longer than
  90 days (or such longer period as the Secretary may provide), and (III)
  the claim form submitted to the carrier includes the second physician's
  unique identifier (provided under the system established under subsection
  (r)) and indicates that the claim meets the requirements of this clause
  for payment to the first physician'.
  (2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to
  services furnished on or after the first day of the first month beginning
  more than 60 days after the date of the enactment of this Act.
  (b) MEDICAID PROGRAM-
  (1) IN GENERAL- Section 1902(a)(32)(C) of such Act (42
  U.S.C. 1396a(a)(32)(C)), as added by section 4708(a)(3) of the Omnibus
  Budget Reconciliation Act of 1990, is amended to read as follows:
  `(C) payment may be made to a physician for services furnished by a
  substitute physician under the circumstances described in clause (D)
  of section 1842(b)(6), except that, for purposes of this subparagraph,
  any reference in such clause to `a carrier' or `the system established
  under subsection (r)' is deemed a reference to the State (or other fiscal
  agent under the State plan) and to the system established under subsection
  (x) of this section, respectively.'.
  (2) EFFECTIVE DATE- (A) The amendment made by paragraph (1) shall apply
  to services furnished on or after the date of the enactment of this Act.
  (B) Until the first day of the first calendar quarter beginning more
  than 60 days after the date the Secretary of Health and Human Services
  established the physician identifier system under section 1902(x) of
  the Social Security Act, the requirement under section 1902(a)(32)(C) of
  such Act that a claim form submitted must include the second physician's
  unique identifier is deemed to be satisfied if the claim form identifies
  (in a manner specified by such Secretary) the second physician.
SEC. 9. REPEAL OF PRO PRECERTIFICATION REQUIREMENT FOR CERTAIN SURGICAL
PROCEDURES.
  (a) IN GENERAL- Section 1164 of the Social Security Act (42 U.S.C. 1320c-13)
  is repealed.
  (b) CONFORMING AMENDMENTS-
  (1) Section 1154 of such Act (42 U.S.C. 1320c-3) is amended--
  (A) in subsection (a), by striking paragraph (12), and
  (B) in subsection (d), by striking `(and except as provided in section
  1164)'.
  (2) Section 1833 of such Act (42 U.S.C. 1395l) is amended--
  (A) in subsection (a)(1)(D)(i), by striking `, or for tests furnished in
  connection with obtaining a second opinion required under section 1164(c)(2)
  (or a third opinion, if the second opinion was in disagreement with the
  first opinion)';
  (B) in subsection (a)(1), by striking clause (G);
  (C) in subsection (a)(2)(A), by striking `to items and services (other
  than clinical diagnostic laboratory tests) furnished in connection with
  obtaining a second opinion required under section 1164(c)(2) (or a third
  opinion, if the second opinion was in disagreement with the first opinion),';
  (D) in subsection (a)(2)(D)(i)--
  (i) by striking `basis,' and inserting `basis or', and
  (ii) by striking `, or for tests furnished in connection with obtaining
  a second opinion required under section 1164(c)(2) (or a third opinion,
  if the second opinion was in disagreement with the first opinion))';
  (E) in subsection (a)(3), by striking `and for items and services furnished
  in connection with obtaining a second opinion required under section
  1164(c)(2), or a third opinion, if the second opinion was in disagreement
  with the first opinion)'; and
  (F) in the first sentence of subsection (b)--
  (i) by striking `(3)' and inserting `and (3)', and
  (ii) by striking `, and (4)' and all that follows up to the period at
  the end.
  (3) Section 1834(g)(1)(B) of such Act (42 U.S.C. 1395m(g)(1)(B)) is amended
  by striking `and for items and services furnished in connection with
  obtaining a second opinion required under section 1164(c)(2), or a third
  opinion, if the second opinion was in disagreement with the first opinion)'.
  (4) Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is amended--
  (A) by adding `or' at the end of paragraph (14),
  (B) by striking `; or' at the end of paragraph (15) and inserting a
  period, and
  (C) by striking paragraph (16).
  (5) The third sentence of section 1866(a)(2)(A) of such Act (42
  U.S.C. 1395w(a)(2)(A)) is amended by striking `, with respect to items and
  services furnished in connection with obtaining a second opinion required
  under section 1164(c)(2) (or a third opinion, if the second opinion was
  in disagreement with the first opinion),'.
SEC. 10. EFFECTIVE DATE.
  The amendments made by this Act (other than by section 8) shall take effect
  on January 1, 1992.