US · guidance
CMS Pub. 100-16, ch. mc86c18b, § 30.2
Payment by Physician Group on Fee-For-Service Basis
If the HCPP pays a physician group on other than a fee-for-service basis, and that
physician group pays its physicians on a fee-for-service basis, reasonable costs shall not
exceed reasonable charges as defined at 42 CFR 405 Subpart E. Subpart E limitations do
not apply if the physician group has effective incentives (as defined in
42 CFR 417.802 (b)(ii)(B)) to avoid unnecessary or unduly costly utilization.
30.3 Payment by HCPP on Fee-For-Service Basis
(Rev. 30, 09-05-03)
If the HCPP pays for physician and other Part B services on a fee-for-service basis, costs
are considered reasonable if they do not exceed:
• Reasonable charges for those services as defined in Subpart E of Part 405 of 42
CFR; and
• The amount CMS would pay for those services if they were furnished to
beneficiaries not enrolled in the HCPP and services from sources not reimbursed
on a reasonable cost basis.
Fee-for service payments to a physician group organized on an individual-practice basis
are not subject to the above definition of reasonableness if the physician group pays its
physicians on a fee-for-service basis and meets the effective incentive definition of
42 CFR 417.802(b)(2)(ii)(B).
History
(Rev. 30, 09-05-03)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
90d6354cbc74de3f9827b5c7e71e95ee1bad5590cdfd184768a2fb3892409892
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