[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: 42CFR1001.1601]



[Page 1161-1162]

 

                         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.  1001.1601  Violations of the limitations on physician charges.



    (a) Circumstance for exclusion. (1) The OIG may exclude a physician 

whom it determines--

    (i) Is a non-participating physician under section 1842(j) of the 

Act;

    (ii) Furnished services to a beneficiary;

    (iii) Knowingly and willfully billed--

    (A) On a repeated basis for such services actual charges in excess 

of the maximum allowable actual charge determined in accordance with 

section 1842(j)(1)(C) of the Act for the period January 1, 1987 through 

December 31, 1990, or

    (B) Individuals enrolled under part B of title XVIII of the Act 

during the statutory freeze for actual charges in excess of such 

physician's actual charges determined in accordance with section 

1842(j)(1)(A) of the Act for the period July 1, 1984 to December 31, 

1986; and''

    (iv) Is not the sole community physician or sole source of essential 

specialized services in the community.

    (2) The OIG will take into account access of beneficiaries to 

physicians' services for which Medicare payment may be made in 

determining whether to impose an exclusion.

    (b) Length of exclusion. (1) In determining the length of an 

exclusion in accordance with this section, the OIG will consider the 

following factors--

    (i) The number of services for which the physician billed in excess 

of the maximum allowable charges;

    (ii) The number of beneficiaries for whom services were billed in 

excess of the maximum allowable charges;

    (iii) The amount of the charges that were in excess of the maximum 

allowable charges;

    (iv) Whether the physician has a documented history of criminal, 

civil or administrative wrongdoing (The lack of any prior record is to 

be considered neutral); and



[[Page 1162]]



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

care items or services furnished by the physician.

    (2) The period of exclusion may not exceed 5 years.



[57 FR 3329, Jan. 29, 1992; 57 FR 9669, Mar. 20, 1992, as amended at 63 

FR 46689, Sept. 2, 1998]