Provider or Other Person Certification Provisions

9050.4.3 – Provider or Other Person Certification Provisions (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) The certification will state that the practitioner or other person: 1. Has informed each of his/her patients in writing that the practitioner or other person has been sanctioned, or, if a hospital, has informed all physicians having privileges at the hospital that it has been sanctioned; 2. If excluded from Medicare and the State health care programs, has informed his/her existing patients in writing that the programs will not pay for items and services the practitioner or other person furnished or ordered (or at the medical direction or on the prescription of an excluded physician) until he/she is reinstated, or, if a hospital, has provided this information to all physicians having privileges at that hospital; 3. If excluded from Medicare and State health care programs, will provide prospective patients—or, if a hospital, physicians requesting privileges at that hospital prior to furnishing or ordering (or in the case of an excluded physician, medically directing or prescribing) services—oral information of both the sanction and that the programs will not pay for services provided, and written notification of the same at the time of the provision of services; 4. If excluded from Medicare and State health care programs and is an entity such as a hospital, has posted a notice in its emergency room, business office, and in all affiliated entities that the programs will not pay for services provided; and 5. Certifies to the truthfulness and accuracy of the notification and the statement in the certification. If the sanctioned practitioner or other person (1) Does not inform his/her patients and does not return the required certification within the 30-day period; or (2) Returns the certification within the 30-day period but OIG obtains reliable evidence that such person nevertheless has not adequately informed new and existing patients of the sanction, OIG: • Will see that the public is notified directly of the identity of the sanctioned practitioner or other person, the finding that the obligation has been violated, and the effective date of any exclusion; and • May consider this failure to adhere to the certification obligation as an adverse factor at the time the sanctioned practitioner or other person requests reinstatement. If the sanctioned practitioner or other person is entitled to a preliminary hearing in accordance with 42 CFR 1004.140(a) and requests such a preliminary hearing, and the Administrative Law Judge (ALJ) decides that he/she poses a risk to program beneficiaries, the sanctioned practitioner or other person would have 30 days from the date of receiving the ALJ’s decision to provide certification to OIG in accordance with 42 CFR 1004.110(d)(1). The date of receipt is presumed to be five (5) days after the date of the ALJ’s decision, unless there is a reasonable showing to the contrary.