100 STAT. 2026
42 USC 1396.
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PUBLIC LAW 99-509—OCT. 21, 1986
criteria set forth in subparagraph (A) and with the succeeding provisions of this paragraph. "(ii) The factors described pursuant to subparagraph (A)(i) with respect to payment for physicians' services shall include, but need not be limited to, the following: "(I) Prevailing charges for a service in a particular locality are significantly in excess of or below prevailing charges in other comparable localities, taking into account the relative costs of furnishing the services in the different localities. "(II) The programs established under this title and title XIX are the sole or primary sources of payment for a service. "(Ill) The marketplace for a service is not truly competitive because of a limited number of physicians who perform that service. "(IV) There have been increases in charges for a service that cannot be explained by inflation or technology. «|^Y) rpj^g charges do not reflect changing technology, increased facility with that technology, or reductions in acquisition or production costs. "(VI) The prevailing charges for a service under this part are substantially higher or lower than the payments made for the service by other purchasers in the same locality. "(iii) In applying subparagraph (A), the Secretary may compare— "(I) the charges and resource costs for related procedures, "(II) charges and resource costs for the procedure over a period of time, "(III) charges for a procedure in different geographic areas, and "(IV) the charges and allowed payments for a procedure under this part and by other payors. "(iv) The factors considered under subparagraph (A)(ii) shall take into account regional differences in fees, unless there is substantial economic justification for a uniform fee or a uniform payment limit. Such substantial economic justification must be explained by the Secretary in the notice and final determination required by paragraph (9). "(v) An adjustment under clause (i) on the basis of a comparison of the prevailing charges in different localities may be made only if the Secretary determines that the prevailing charge allowed in one locality is out of line with prevailing charges allowed in other localities after accounting for differences in practice costs. «(yj) IJJ ^i^jg subparagraph, 'resource costs' include factors such as the time required to provide a procedure (including pre-procedure evaluation and post-procedure follow-up), the complexity of the procedure, the training required to perform the procedure, and the risk involved in the procedure. "(C) In determining whether to adjust payment rates under subparagraph (B)(i), the Secretary shall consider the potential impacts on quality, access, and beneficiary liability of the adjustment, including the likely effects on assignment rates, reasonable charge reductions on unassigned claims, and participation rates of physicians.". (b) INHERENT REASONABLENESS PROCEDURES.—Section 1842(b) of the Social Security Act (42 U.S.C. 1395u(b)) is amended by redesignating paragraph (9) as paragraph (11) and inserting after paragraph (8) the following new paragraphs: -
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