CMS Pub. 100-04, ch. 1, § 30.2.14

A. Disseminating Information

From time to time, A/B MACs must disseminate through professional relations media

information regarding the prohibition in §30.2.

A/B MACs Part A

The following language may be used by A/B MACs Part A or adapted for this purpose:

The Medicare law prohibits us from paying benefits due a provider to another person or

organization under an assignment, power of attorney, or any other arrangement whereby

that other person or organization receives those payments directly. There are the

following exceptions to this rule:

• CMS may pay a provider’s benefits (in the provider’s name) to a

billing or collection agent, if:

o The agent receives the payment under an agency agreement with the

provider;

o The agent’s compensation is not related in any way

to the dollar amounts billed or collected;

o The agent’s compensation is not dependent upon

the actual collection of payment;

o The agent acts under instructions which the

provider may modify or revoke at any time; and

o The agent, in receiving payment, acts only in the

providers’ behalf.

• CMS may pay the providers’ benefits in accordance with an

assignment established by, or pursuant to the order of, a court of

competent jurisdiction.

A provider should notify us immediately if:

• CMS has been mailing its benefits to the address of another person or

organization;

• The provider has given that other person or organization power of

attorney or other advance authority to negotiate its benefit checks; and

• None of the above exceptions that would permit payment to

another person or organization apply in the provider’s case.

A provider which hereafter enters into or continues such a prohibited payment

arrangement may have its participation in the program terminated and its right to receive

assigned payment for physician services revoked.

A/B MACs Part B and DME MACs

An A/B MAC Part B and DME MAC may use or adapt the following language for

notification:

The Medicare law prohibits us from paying benefits due a physician or other supplier of

health care items and services, to another person or organization, under a reassignment or

power of attorney or under any other arrangement whereby that other person or

organization receives those payments directly. There are the following exceptions to this

rule:

• CMS may pay a physician’s or supplier’s employer under the terms

of his/her employment.

• CMS may pay a hospital, clinic, or other facility for services

furnished by the physician or supplier in the facility, in accordance with

the physician’s or supplier’s agreement with the facility.

• CMS may pay a group practice prepayment plan, prepaid health plan, or

• HMO for services of physicians and suppliers associated with the plan.

• CMS may pay a physician, medical group, or other supplier for the

technical component (TC) or professional component (PC) of diagnostic

tests (other than clinical diagnostic tests) that are subject to the anti-markup payment limitation.

• CMS may pay the patient’s regular physician or physical therapist

for services provided to his/her patients by another physician or physical

therapist on an occasional, reciprocal basis

• CMS may pay the patient’s regular physician or physical therapist

for services of a substitute physician or physical therapist during the

absence of the regular physician or physical therapist where the regular

physician or physical therapist pays the substitute on a per diem or similar

fee-for-time basis.

• CMS may pay a physician’s or supplier’s benefits in his/her name

to a billing or collection agent, e.g., a medical bureau, if:

o The agent receives the payment under an agency

agreement with the physician or supplier;

o The agent’s compensation is not related in any way

to the dollar amounts billed or collected;

o The agent’s compensation is not dependent upon

the actual collection of payment;

o The agent acts under instructions which the

physician or supplier may modify or revoke at any time; and

o The agent, in receiving the payment, acts only on

the physician’s or supplier’s behalf.

• CMS may pay a physician’s or supplier’s benefits in accordance

with a reassignment established by, or pursuant to the order of, a court of

competent jurisdiction.

A physician or supplier should notify us immediately if:

• CMS has been mailing his/her benefits to the address of another

person or organization;

• The physician has given that other person or organization power of

attorney or other advance authority to negotiate the physician’s benefit

checks; and

• None of the above exceptions which would permit payment to

another person or organization apply in his/her case.

A physician or other eligible recipient of assigned payment who hereafter enters

into or continues such a prohibited payment arrangement may have the right to

receive assigned payment revoked.