[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: 42CFR1004.30]



[Page 1190]

 

                         TITLE 42--PUBLIC HEALTH

 

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

 

PART 1004_IMPOSITION OF SANCTIONS ON HEALTH CARE PRACTITIONERS AND 

 

                     Subpart C_QIO Responsibilities

 

Sec.  1004.30  Basic responsibilities.





    (a) The QIO must use its authority or influence to enlist the 

support of other professional or government agencies to ensure that each 

practitioner or other person complies with the obligations specified in 

Sec.  1004.10.

    (b) When the QIO identifies situations where an obligation specified 

in Sec.  1004.10 is violated, it will afford the practitioner or other 

person reasonable notice and opportunity for discussion and, if 

appropriate, a suggested method for correcting the situation and a time 

period for a corrective action in accordance with Sec. Sec.  1004.40 and 

1004.60.

    (c) The QIO must submit a report to the OIG after the notice and 

opportunity provided under paragraph (b) of this section and, if 

appropriate, the opportunity to enter into and complete a corrective 

action plan (CAP) if the QIO finds that the practitioner or other person 

has--

    (1) Failed substantially to comply with any obligation in a 

substantial number of admissions; or

    (2) Grossly and flagrantly violated any obligation in one or more 

instances.

    (d) The QIO report to the OIG must comply with the provisions of 

Sec.  1004.80.

    (e) If a practitioner or other person relocates to another QIO area 

prior to a finding of a violation or sanction recommendation, and the 

originating QIO--

    (1) Is able to make a finding, the originating QIO must, as 

appropriate, close the case or forward a sanction recommendation to the 

OIG; or

    (2) Cannot make a finding, the originating QIO must forward all 

documentation regarding the case to the QIO with jurisdiction, and 

notify the practitioner or other person of this action.

    (f) The QIO must deny payment for services or items furnished or 

ordered (or at the medical direction or on the prescription of an 

excluded physician) by an excluded practitioner or other person when the 

QIO identifies the services or items. It must report the findings to the 

Centers for Medicare & Medicaid Services.