§ 1645. Direct billing of medicare, medicaid, and other third party payors

(a) Establishment of direct billing program

(1) In general

The Secretary shall establish a program under which Indian tribes, tribal organizations, and Alaska Native health organizations that contract or compact for the operation of a hospital or clinic of the Service under the Indian Self-Determination and Education Assistance Act [25 U.S.C. 450 et seq.] may elect to directly bill for, and receive payment for, health care services provided by such hospital or clinic for which payment is made under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) (in this section referred to as the “medicare program”), under a State plan for medical assistance approved under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) (in this section referred to as the “medicaid program”), or from any other third party payor.

(2) Application of 100 percent FMAP

The third sentence of section 1905(b) of the Social Security Act (42 U.S.C. 1396d (b)) shall apply for purposes of reimbursement under the medicaid program for health care services directly billed under the program established under this section.

(b) Direct reimbursement

(1) Use of funds

Each hospital or clinic participating in the program described in subsection (a) of this section shall be reimbursed directly under the medicare and medicaid programs for services furnished, without regard to the provisions of section 1880(c) of the Social Security Act (42 U.S.C. 1395qq (c)) and sections 1642 (a) and 1680c (b)(2)(A) of this title, but all funds so reimbursed shall first be used by the hospital or clinic for the purpose of making any improvements in the hospital or clinic that may be necessary to achieve or maintain compliance with the conditions and requirements applicable generally to facilities of such type under the medicare or medicaid programs. Any funds so reimbursed which are in excess of the amount necessary to achieve or maintain such conditions shall be used—

(A) solely for improving the health resources deficiency level of the Indian tribe; and

(B) in accordance with the regulations of the Service applicable to funds provided by the Service under any contract entered into under the Indian Self-Determination Act (25 U.S.C. 450f et seq.).

(2) Audits

The amounts paid to the hospitals and clinics participating in the program established under this section shall be subject to all auditing requirements applicable to programs administered directly by the Service and to facilities participating in the medicare and medicaid programs.

(3) Secretarial oversight

The Secretary shall monitor the performance of hospitals and clinics participating in the program established under this section, and shall require such hospitals and clinics to submit reports on the program to the Secretary on an annual basis.

(4) No payments from special funds

Notwithstanding section 1880(c) of the Social Security Act (42 U.S.C. 1395qq (c)) or section 1642 (a) of this title, no payment may be made out of the special funds described in such sections for the benefit of any hospital or clinic during the period that the hospital or clinic participates in the program established under this section.

(1) Application

Except as provided in paragraph (2)(B), in order to be eligible for participation in the program established under this section, an Indian tribe, tribal organization, or Alaska Native health organization shall submit an application to the Secretary that establishes to the satisfaction of the Secretary that—

(A) the Indian tribe, tribal organization, or Alaska Native health organization contracts or compacts for the operation of a facility of the Service;

(B) the facility is eligible to participate in the medicare or medicaid programs under section 1880 or 1911 of the Social Security Act (42 U.S.C. 1395qq; 1396j);

(D) the facility—

(i) is accredited by an accrediting body as eligible for reimbursement under the medicare or medicaid programs; or

(ii) has submitted a plan, which has been approved by the Secretary, for achieving such accreditation.

(2) Approval

(A) In general

The Secretary shall review and approve a qualified application not later than 90 days after the date the application is submitted to the Secretary unless the Secretary determines that any of the criteria set forth in paragraph (1) are not met.

(B) Grandfather of demonstration program participants

Any participant in the demonstration program authorized under this section as in effect on the day before November 1, 2000, shall be deemed approved for participation in the program established under this section and shall not be required to submit an application in order to participate in the program.

An approval by the Secretary of a qualified application under subparagraph (A), or a deemed approval of a demonstration program under subparagraph (B), shall continue in effect as long as the approved applicant or the deemed approved demonstration program meets the requirements of this section.

(d) Examination and implementation of changes

(1) In general

The Secretary, acting through the Service, and with the assistance of the Administrator of the Centers for Medicare & Medicaid Services, shall examine on an ongoing basis and implement—

(A) any administrative changes that may be necessary to facilitate direct billing and reimbursement under the program established under this section, including any agreements with States that may be necessary to provide for direct billing under the medicaid program; and

(B) any changes that may be necessary to enable participants in the program established under this section to provide to the Service medical records information on patients served under the program that is consistent with the medical records information system of the Service.

(2) Accounting information

The accounting information that a participant in the program established under this section shall be required to report shall be the same as the information required to be reported by participants in the demonstration program authorized under this section as in effect on the day before November 1, 2000. The Secretary may from time to time, after consultation with the program participants, change the accounting information submission requirements.

(e) Withdrawal from program

A participant in the program established under this section may withdraw from participation in the same manner and under the same conditions that a tribe or tribal organization may retrocede a contracted program to the Secretary under authority of the Indian Self-Determination Act [25 U.S.C. 450f et seq.]. All cost accounting and billing authority under the program established under this section shall be returned to the Secretary upon the Secretary’s acceptance of the withdrawal of participation in this program.

U.S. Code

§ 1645. Direct billing of medicare, medicaid, and other third party payors