TITLE 42 - PUBLIC HEALTH

CHAPTER V - OFFICE OF INSPECTOR GENERAL - HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

SUBCHAPTER B - OIG AUTHORITIES

PART 1001 - PROGRAM INTEGRITY - MEDICARE AND STATE HEALTH CARE PROGRAMS

subpart c - PERMISSIVE EXCLUSIONS

1001.1701 - Billing for services of assistant at surgery during cataract operations.

  (a) Circumstance for exclusion. The OIG may exclude a physician whom it determines (1) Has knowingly and willfully presented or caused to be presented a claim, or billed an individual enrolled under Part B of the Medicare program (or his or her representative) for: (i) Services of an assistant at surgery during a cataract operation, or (ii) Charges that include a charge for an assistant at surgery during a cataract operation; (2) Has not obtained prior approval for the use of such assistant from the appropriate Utilization and Quality Control Quality Improvement Organization (QIO) or Medicare carrier; and (3) Is not the sole community physician or sole source of essential specialized services in the community.

  (b) 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.

  (c) 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 instances for which claims were submitted or beneficiaries were billed for unapproved use of assistants during cataract operations; (ii) The amount of the claims or bills presented; (iii) The circumstances under which the claims or bills were made, including whether the services were medically necessary; (iv) Whether approval for the use of an assistant was requested from the QIO or carrier; (v) 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 (vi) 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 3330, Jan. 29, 1992, as amended at 63 FR 46690, Sept. 2, 1998]