CMS Pub. 100-01, ch. 5, § 10.1.6

Furnishes More Expensive Services Not Requested by Beneficiary

(Rev. 1, 09-11-02)

A provider that customarily furnishes an individual items or services that are more

expensive than the items or services determined to be necessary in the efficient delivery

of needed health services, may charge an individual entitled to benefits under Medicare

for such more expensive items or services even though not requested by the individual.

The charge, however, may not exceed the amount by which the cost of (or, if less, the

customary charges for) more expensive items or services furnished by such provider in

the second cost reporting period immediately preceding the cost reporting period in

which such charges are imposed, exceeds the applicable limit imposed under the

provisions of 42 CFR 413.30.

This charge may be made only if:

• The A/B MAC (A) or (HHH) determines that the charges have been calculated

properly in accordance with the provisions of this regulation section;

• The services are not emergency services as defined in §20.1 or §20.2 of this

chapter;

• The admitting physician has no direct or indirect financial interest in such

provider;

• CMS has provided notice to the public through notice in a newspaper of general

circulation servicing the provider's locality and such other notice as the Secretary

may require, of any charges the provider is authorized to impose on individuals

entitled to benefits under Medicare on account of costs in excess of the costs

determined to be necessary in the efficient delivery of needed health services

under Medicare; and

• The provider has identified such charges to such individual or person acting on

his/her behalf as charges to meet the costs in excess of the costs determined to be

necessary in the efficient delivery of needed health services under Medicare.