1001.1701—Billing for services of assistant at surgery during cataract operations.
(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:
(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;
(iii)
The circumstances under which the claims or bills were made, including whether the services were medically necessary;
(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.
[57 FR 3330, Jan. 29, 1992, as amended at 63 FR 46690, Sept. 2, 1998]