[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

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

[CITE: 42CFR1001.1201]



[Page 1158-1159]

 

                         TITLE 42--PUBLIC HEALTH

 

      GENERAL--HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

PART 1001_PROGRAM INTEGRITY_MEDICARE AND STATE HEALTH CARE PROGRAMS--

 

                     Subpart C_Permissive Exclusions

 

Sec.  1001.1201  Failure to provide payment information.



    (a) Circumstance for exclusion. The OIG may exclude any individual 

or entity that furnishes items or services for which payment may be made 

under Medicare or any of the State health care programs and that:



[[Page 1159]]



    (1) Fails to provide such information as is necessary to determine 

whether such payments are or were due and the amounts thereof, or

    (2) Has refused to permit such examination and duplication of its 

records as may be necessary to verify such information.

    (b) Length of exclusion. The following factors will be considered in 

determining the length of an exclusion under this section--

    (1) The number of instances where information was not provided;

    (2) The circumstances under which such information was not provided;

    (3) The amount of the payments at issue;

    (4) Whether the individual or entity has a documented history of 

criminal, civil or administrative wrongdoing (The lack of any prior 

record is to be considered neutral); and

    (5) The availability of alternative sources of the type of health 

care items or services provided by the individual or entity.



[57 FR 3330, Jan. 29, 1992, as amended at 63 FR 46689, Sept. 2, 1998]