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

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§ 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; and

(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).

(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; 82 FR 4116, Jan. 12, 2017]

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United States Code

Title 42 published on 15-May-2018 04:40

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 1001 after this date.

  • 2017-12-27; vol. 82 # 247 - Wednesday, December 27, 2017
    1. 82 FR 61229 - Solicitation of New Safe Harbors and Special Fraud Alerts
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Office of Inspector General
      Notification of intent to develop regulations.
      To ensure consideration, public comments must be delivered to the address provided below by no later than 5 p.m. on February 26, 2018.
      42 CFR Part 1001
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