If the admitting physician has a direct or indirect financial interest of 5 percent
or more in the provider, the latter cannot impose charges for excess costs upon the
Authorization to make charges for excess costs is effective only prospectively and
does not extend beyond the end of the cost period for which the cost limit is applicable.
Thus, where all requirements for imposing charges for excess costs (e.g., public notice
of the charges) are not met, until after the beginning of the cost period for which
the charges would be applicable, the charges can be made only during the remainder
of the cost period.
Where program reimbursement for items or services to which the limits are applied
plus the provider’s charges to beneficiaries exceed the provider’s actual cost for
the cost period, program reimbursement will be reduced by the amount of the excess.
Where a provider requests a review of the applicable costs limits and the limit is
raised as a result (e.g., because of a typical services) the provider is responsible
for refunding to the beneficiary (or whoever paid the charges) amounts which, on the
basis of the correction of the cost limit, were erroneously collected. Where the total
erroneously collected on this basis from a beneficiary during the cost period is $5
or less, the provider need not make a refund unless the payer requests it. However,
any amounts which are not refunded, either because they are within this tolerance
or because the provider is unable to locate the beneficiary, will be offset against