Identification Number:
DI 39545 TN 6
Intended Audience:See Transmittal Sheet
Originating Office:DCO ODD
Title:Purchased Medical Services
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 395 – DDS Fiscal and Administrative Management
Subchapter 45 – Purchased Medical Services
Transmittal No. 6, 01/14/2022

Audience

ODD-DDS: ADM;

Originating Component

ODD

Effective Date

Upon Receipt

Background

Concerns about documentation requirements for higher than normal consultative examination (CE) fees and CE travel costs and questions about where to document these expenses in their budget reporting.

Examples specifically cited include:

  • Paying a CE provider to travel to a remote location to perform CEs. This includes pay for travel, lodging, space rental to perform the exams, etc…

  • Paying for CEs and or MER in Canada which far exceed fee schedule rates.

Summary of Changes

DI 39545.600 Fee Schedules

We made the following changes in

Subsection D:

From the original:

“Each State should be cost-efficient and make every attempt to negotiate fees below the highest allowable rates.

  • DDS should not enter into any negotiated agreement that would result in fee payments in excess of the maximum amount of their fee schedule without obtaining prior written approval from the RO.

  • DDSs are responsible for maintaining oversight of all CE providers to ensure compliance with the CE procedures and fee schedules.”

  • This is being changed to the following language:

    “Each State should be cost-efficient and make every attempt to negotiate fees below the highest allowable rates.

    • DDS should not enter into any negotiated agreement that would result in fee payments in excess of the maximum amount of their fee schedule without obtaining prior written approval from the RO.

    • States must follow federal and state guidance (including State Agency Fee Schedule) when seeking approval for charges that exceed the fee schedule. This includes costs for travel (airfare, car, etc), per diem for food, and lodging.

    • Regional Offices review requests and maintain records when medical services exceed the fee schedule.

    • DDS report costs in the Medical Costs of Consultative Examinations section of the eMOR and Form SSA-4513 – State Agency Report of Obligations for SSA Disability Programs.

    NOTE: Do not record costs for medical services above the fee schedule in the Other or Applicant Travel section of the eMOR under any circumstance.

    • States must provide a description of any CE fee schedule changes and all exceptions (include a description of any volume medical provider discounts) in the Annual Oversight Report.

    • DDS are responsible for maintaining oversight of all CE providers to ensure compliance with the CE procedures and fee schedules.”

DI 39545.600 Fee Schedules

CITATIONS:

Regulations 20 CFR 404.1624 and 404.1519k

A. Policy – fee schedule rates

Each State determines its rates of payment for purchasing medical or other services necessary to make determinations of disability.

B. Procedure – DDS responsibilities

  • Maintain documentation to support the rates of payment it uses.

  • Provide documentation and obtain RO approval when fee schedules increase. The request could include documentation of the difficulties in obtaining the necessary testing/source, specific proposed fees with an explanation of how those fees were derived, and an analysis of projected change in annual medical costs.

C. Policy – laboratory fees

If a consultative examination (CE) provider bill (or a request for payment for a provider's services) includes a charge for a laboratory test for which payment may be made, the amount payable is determined as follows.

  1. 1. 

    If the bill (or payment request) indicates the test was personally performed or supervised by the provider who submitted the bill (or by another provider with whom that provider shares his/her practice), the payment will be based on the provider's usual and customary charge for the test or the rates of payment in the State’s fee schedule, whichever is the lesser amount.

  2. 2. 

    If the bill (or payment request) indicates the test was performed by an independent laboratory, the payment will be based on the billed cost of the independent laboratory or the State’s fee schedule, whichever is the lesser amount. The provider may be paid a nominal payment for obtaining laboratory samples, e.g., drawing blood, if the provider bills for the service. However, the total reimbursement may not exceed the State’s fee schedule.

NOTE: States are responsible for monitoring and overseeing the rates of payment it uses to ensure compliance with DI 39545.600C.1. and DI 39545.600C.2.

D. Policy – negotiated rates

Each State should be cost-efficient and make every attempt to negotiate fees below the highest allowable rates.

  • DDS should not enter into any negotiated agreement that would result in fee payments in excess of the maximum amount of their fee schedule without obtaining prior written approval from the RO.

  • States must follow federal and state guidance (including State Agency Fee Schedule) when seeking approval for charges that exceed the fee schedule. This includes costs for travel (airfare, car, etc), per diem for food, and lodging.

    • Regional Offices review requests and maintain records when medical services exceed the fee schedule.

    • DDS report costs in the Medical Costs of Consultative Examinations section of the eMOR and Form SSA-4513 – State Agency Report of Obligations for SSA Disability Programs.

NOTE: Do not record costs for medical services above the fee schedule in the Other or Applicant Travel section of the eMOR under any circumstance.

  • States must provide a description of any CE fee schedule changes and all exceptions (include a description of any volume medical provider discounts) in the Annual Oversight Report.

  • DDS are responsible for maintaining oversight of all CE providers to ensure compliance with the CE procedures and fee schedules.


DI 39545 TN 6 - Purchased Medical Services - 1/14/2022