[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: 42CFR455.2]



[Page 332-333]

 

                         TITLE 42--PUBLIC HEALTH

 

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

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 455_PROGRAM INTEGRITY: MEDICAID--Table of Contents

 

Sec.  455.2  Definitions.



    As used in this part unless the context indicates otherwise--

    Abuse means provider practices that are inconsistent with sound 

fiscal, business, or medical practices, and result in an unnecessary 

cost to the Medicaid program, or in reimbursement for services that are 

not medically necessary or that fail to meet professionally recognized 

standards for health care. It also includes recipient practices that 

result in unnecessary cost to the Medicaid program.

    Conviction or Convicted means that a judgment of conviction has been 

entered by a Federal, State, or local court, regardless of whether an 

appeal from that judgment is pending.

    Exclusion means that items or services furnished by a specific 

provider who has defrauded or abused the Medicaid program will not be 

reimbursed under Medicaid.

    Fraud means an intentional deception or misrepresentation made by a 

person with the knowledge that the deception could result in some 

unauthorized benefit to himself or some other person. It includes any 

act that constitutes fraud under applicable Federal or State law.

    Furnished refers to items and services provided directly by, or 

under the direct supervision of, or ordered by, a practitioner or other 

individual (either as an employee or in his or her own capacity), a 

provider, or other supplier of services. (For purposes of denial of 

reimbursement within this part, it does not refer to services ordered by 

one party but billed for and provided by or under the supervision of 

another.)

    Practitioner means a physician or other individual licensed under 

State law to practice his or her profession.



[[Page 333]]



    Suspension means that items or services furnished by a specified 

provider who has been convicted of a program-related offense in a 

Federal, State, or local court will not be reimbursed under Medicaid.



[48 FR 3755, Jan. 27, 1983, as amended at 50 FR 37375, Sept. 13, 1985; 

51 FR 34788, Sept. 30, 1986]