N.Y. Comp. Codes R. & Regs. tit. 18 § 533.1

Current through Register Vol. 46, No. 45, November 2, 2024

Section 533.1 - Payment for physician's services to hospitalized patients

(a) Expenditures by social services districts for their payments to a physician for services rendered to a hospitalized patient shall be subject to State reimbursement as follows:

(1) when the physician has the responsibility for the care of the patient; or

(2) when the physician's services were rendered as a consultant, surgical assistant, or for a special service at the request of the physician responsible for the care of the patient.

(b) State reimbursement shall not be available:

(1) for compensation paid to a physician for the care of hospitalized patients when such compensation has been included as an element of costs reflected in a hospital rate approved by the State Director of the Budget pursuant to section 2807 of the Public Health Law;

(2) for services provided by a physician or physician's associate or a registered specialist's assistant employed by the physician to patients other than those determined in accordance with Part 505 of this Subchapter by the Commissioner of Health or his designee.

(c) Maximum reimbursable fee schedule for physician provided inpatient care at hospitals with approved training programs.

(1) Conditions for payment:

(i) Individual private practitioner. Qualified physicians may be paid on a fee-for-service basis for direct care of hospital inpatients when their hospital salary is not paid for purposes of providing direct patient care; i.e., when the salary is paid exclusively for hospital activities such as teaching, various administrative duties (department heads, etc.) or for research.

(ii) Group practice. Payments for physicians' services on a group care basis may begin September 1, 1968, provided that the State Department of Health has approved a plan submitted in accordance with section 405.22 of 10 NYCRR, by the hospital describing how the group care will function, or is already functioning, how the requirements of such section are being met, and to which services it will apply.

(2) Conditions barring payment. Payment on a fee-for-service basis to a salaried hospital physician may not be made when:

(i) any portion of the salary paid by the hospital to such salaried physicians is for direct care of hospital inpatients or outpatients; or

(ii) there is any prohibition for such payment in law, in the rules of particular hospital or in the contractual arrangement with the salaried physician or group.

(3) Medicine (effective April 1, 1974).

9020 First visit, history, examination and treatment ............$6.50

9021 Subsequent visit, including treatment ............ 5.00

During the first week of care, payments for no more than one visit daily shall be subject to reimbursement. Thereafter, payment for no more than three visits weekly shall be subject to reimbursement.

(4) Surgery. Reimbursement for inpatient surgical care shall be limited to 80 percent of the maximum reimbursable allowances as set out in section 533.5 of this Part when after-care is provided in the outpatient department. Payment for such after-care shall be made made on a per-visit basis to the hospital and the outpatient physician in accordance with prescribed procedures.

(d) State reimbursement for payment to physicians providing emergency services under contract with certain hospitals. Maximum reimbursable fees for payments made to physicians providing emergency services under contract with a hospital, effective April 1, 1974, shall be as follows:

(1) Reimbursement for inpatient emergency care shall be limited to 70 percent of the maximum reimbursable allowances set out in section 533.4 of this Part.

(2) Reimbursement for outpatient emergency care shall be limited to 70 percent of the maximum reimbursable allowances set out in section 533.4 of this Part.

(3) If the contract with physicians either individually, or as a group includes the provision that the hospital will pay to such physicians or physician group an amount equal to the difference between the billings for physicians' services and an established guaranteed amount, the hospitals may include, as an allowable hospital cost for outpatient rate determination purposes, either the amount paid under the guarantee or 15 percent of the guaranteed amount, whichever is less. Such amount shall not be included in determination of the inpatient rate.

(4) Salaries of physicians employed by a hospital to provide patient care are included as hospital costs in determining inpatient and outpatient reimbursement rates and therefore, no separate payments shall be made to such salaried physicians.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 533.1