[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR489.54]



[Page 954-955]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 489_PROVIDER AGREEMENTS AND SUPPLIER APPROVAL--Table of Contents

 

 Subpart E_Termination of Agreement and Reinstatement After Termination

 

Sec. 489.54  Termination by the OIG.



    (a) Basis for termination. (1) The OIG may terminate the agreement 

of any provider if the OIG finds that any of the following failings can 

be attributed to that provider.

    (i) It has knowingly and willfully made, or caused to be made, any 

false statement or representation of a material fact for use in an 

application or request for payment under Medicare.

    (ii) It has submitted, or caused to be submitted, requests for 

Medicare payment of amounts that substantially exceed the costs it 

incurred in furnishing the services for which payment is requested.

    (iii) It has furnished services that the OIG has determined to be 

substantially in excess of the needs of individuals or of a quality that 

fails to meet professionally recognized standards of health care. The 

OIG will not terminate a provider agreement under paragraph (a) if CMS 

has waived a disallowance with respect to the services in question on 

the grounds that the provider and the beneficiary could not reasonably 

be expected to know that payment would



[[Page 955]]



not be made. (The rules for determining such lack of knowledge are set 

forth in Sec. Sec. 405.330 through 405.334 of this chapter.)

    (b) Notice of termination. The OIG will give the provider notice of 

termination at least 15 days before the effective date of termination of 

the agreement, and will concurrently give notice of termination to the 

public.

    (c) Appeal by the provider. A provider may appeal a termination of 

its agreement by the OIG in accordance with subpart O of part 405 of 

this chapter.

    (d) Other applicable rules. The termination of a provider agreement 

by the OIG is subject to the additional procedures specified in 

Sec. Sec. 1001.105 through 1001.109 of this title for notice and 

appeals.



[51 FR 24492, July 3, 1986, as amended at 51 FR 34788, Sept. 30, 1986]