Page:United States Statutes at Large Volume 100 Part 3.djvu/216

 100 STAT. 2024

PUBLIC LAW 99-509—OCT. 21, 1986

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42 USC 1320c. 42 USC 1395y.

contracts.

Sanctions. 42 USC 1395u note. 42 USC 1395U.

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"(i) a nonparticipating physician furnishes services to an individual enrolled for benefits under this part, "(ii) payment for such services is not accepted on an assignment-related basis, "(iii) a carrier determines under this part or a peer review organization determines under part B of title XI that payment may not be made by reason of section 1862(a)(1) because a service otherwise covered under this title is not reasonable and necessary under the standards described in that section, and "(iv) the physician has collected any amounts for such services, the physician shall refund on a timely basis to the individual (and shall be liable to the individual for) any amounts so collected. "(B) A refund under subparagraph (A) is considered to be on a timely oasis only if— "(i) in the case of a physician who does not request reconsideration or seek appeal on a timely basis, the refund is made within 30 days after the date the physician receives a denial notice under paragraph (2), or "(ii) in the case in which such a reconsideration or appeal is taken, the refund is made within 15 days after the date the physician receives notice of an adverse determination on reconsideration or appeal. "(C) Subparagraph (A) shall not apply to the furnishing of a service by a physician to an individual if— "(i) the physician did not know and could not reasonably have been expected to know that payment may not be made for the service by reason of section 1862(a)(1), or "(ii) before the service was provided, the individual was informed that payment under this part may not be made for the specific service and the individual has agreed to pay for that service. "(2) Each carrier with a contract in effect under this section with respect to physicians and each peer review organization with a contract under part B of title XI shall send any notice of denial of payment for physicians' services based on section 1862(a)(1) and for which payment is not requested on an assignment-related basis to the physician and the individual involved. "(3) If a physician knowingly and willfully fails to make refunds in violation of paragraph (1)(A), the Secretary may apply sanctions against such physician in accordance with subsection (j)(2).". (2) EFFECTIVE DATE.—The amendment made by paragraph (1) shall apply to services furnished on or after October 1, 1987. (d) DISCLOSURE OF INFORMATION OF UNASSIGNED CLAIMS FOR CERTAIN PHYSICIANS' SERVICES.—

(1) IN GENERAL.—Section 1842 of the Social Security Act, as amended by subsection (c)(1), is further amended by adding at the end the following new subsection: "(m)(l) In the case of a nonparticipating physician who— "(A) performs an elective surgical procedure for an individual ^^n enrolled for benefits under this part and for which the physi*' * cian's actual charge is at least $500, and "(B) does not accept payment for such procedure on an assignment-related basis, the physician must disclose to the individual, in writing and in a form approved by the Secretary, the physician's estimated actual charge for the procedure, the estimated approved charge under this

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