[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: 42CFR1003.100]



[Page 1172-1173]

 

                         TITLE 42--PUBLIC HEALTH

 

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

 

PART 1003_CIVIL MONEY PENALTIES, ASSESSMENTS AND EXCLUSIONS--Table 

 

Sec.  1003.100  Basis and purpose.



    (a)Basis. This part implements sections 1128(c), 1128A, 1140, 1860D-

31(i)(3), 1876(i)(6), 1877(g), 1882(d) and 1903(m)(5) of the Social 

Security Act; sections 421(c) and 427(b)(2) of Pub. L. 99-660; and 

section 201(i) of Pub. L. 107-188 (42 U.S.C. 1320-7(c), 1320a-7a, 1320b-

10, 1395w-141(i)(3), 1395dd(d)(1), 1395mm, 1395ss(d), 1396b(m), 

11131(c), 11137(b)(2) and 262).

    (b) Purpose. This part--

    (1) Provides for the imposition of civil money penalties and, as 

applicable, assessments against persons who--

    (i) Have knowingly submitted certain prohibited claims under Federal 

health care programs;

    (ii) Seek payment in violation of the terms of an agreement or a 

limitation on charges or payments under the Medicare program, or a 

requirement not to charge in excess of the amount permitted under the 

Medicaid program;

    (iii) Give false or misleading information that might affect the 

decision to discharge a Medicare patient from the hospital;

    (iv)(A) Fail to report information concerning medical malpractice 

payments or who improperly disclose, use or permit access to information 

reported under part B of title IV of Public Law 99-660, and regulations 

specified in 45 CFR part 60, or

    (B) Are health plans and fail to report information concerning 

sanctions or other adverse actions imposed on providers as required to 

be reported to the Healthcare Integrity and Protection Data Bank (HIPDB) 

in accordance with section 1128E of the Act;

    (v) Misuse certain Departmental and Medicare and Medicaid program 

words, letters symbols or emblems;

    (vi) Violate a requirement of section 1867 of the Act or Sec.  

489.24 of this title;

    (vii) Substantially fail to provide an enrollee with required 

medically necessary items and services; engage in certain marketing, 

enrollment, reporting, claims payment, employment or contracting abuses; 

or do not meet the requirements for physician incentive plans for 

Medicare specified in Sec. Sec.  417.479(d) through (f) of this title;

    (viii) Present or cause to be presented a bill or claim for 

designated health services (as defined in Sec.  411.351 of this title) 

that they know, or should know, were furnished in accordance with a 

referral prohibited under Sec.  411.353 of this title;

    (ix) Have collected amounts that they know or should know were 

billed in violation of Sec.  411.353 of this title and have not refunded 

the amounts collected on a timely basis;

    (x) Are physicians or entities that enter into an arrangement or 

scheme that they know or should know has as a principal purpose the 

assuring of referrals by the physician to a particular entity which, if 

made directly, would violate the provisions of Sec.  411.353 of this 

title;



[[Page 1173]]



    (xi) Are excluded, and who retain an ownership or control interest 

of five percent or more in an entity participating in Medicare or a 

State health care program, or who are officers or managing employees of 

such an entity (as defined in section 1126(b) of the Act);

    (xii) Offer inducements that they know or should know are likely to 

influence Medicare or State health care program beneficiaries to order 

or receive particular items or services;

    (xiii) Are physicians who knowingly misrepresent that a Medicare 

beneficiary requires home health services;

    (xiv) Have submitted, or caused to be submitted, certain prohibited 

claims, including claims for services rendered by excluded individuals 

employed by or otherwise under contract with such person, under one or 

more Federal health care programs;

    (xv) Violate the Federal health care programs' anti-kickback statute 

as set forth in section 1128B of the Act;

    (xvi) Violate the provisions of part 73 of this title, implementing 

section 351A(b) and (c) of the Public Health Service Act, with respect 

to the possession and use within the United States, receipt from outside 

the United States, and transfer within the United States, of select 

agents and toxins in use, or transfer of listed biological agents and 

toxins; or

    (xvii) Violate the provisions of part 403, subpart H of this title, 

implementing the Medicare prescription drug discount card and 

transitional assistance program, by misleading or defrauding program 

beneficiaries, by overcharging a discount program enrollee, or by 

misusing transitional assistance funds.

    (2) Provides for the exclusion of persons from the Medicare or State 

health care programs against whom a civil money penalty or assessment 

has been imposed, and the basis for reinstatement of persons who have 

been excluded; and

    (3) Sets forth the appeal rights of persons subject to a penalty, 

assessment and exclusion.



[65 FR 24414, Apr. 26, 2000, as amended at 67 FR 11935, Mar. 18, 2002; 

67 FR 76905, Dec. 13, 2002; 69 FR 28845, May 19, 2004]