Imposing Sanctions for Specific MA Contract Violations

30 - Imposing Sanctions for Specific MA Contract Violations (Rev. 73, Issued: 09-30-05, Effective Date: 09-30-05) CMS may impose certain intermediate sanctions, including CMPs, on MA organizations for the same reasons that we can terminate an MA organization's contract under §422.510(a). In cases involving fraud and abuse DHHS/ OIG, and not CMS, maintains the authority to impose CMPs. Federal Regulations at 42 CFR 422.510(a)(1) through (a)(12) permit CMS to terminate an MA organization's contract or impose intermediate sanctions if the Agency determines: • The MA organization has failed substantially to carry out the terms of its contract with CMS; • The MA organization is carrying out its contract with CMS in a manner that is inconsistent with the effective and efficient implementation of this part; • CMS determines that the MA organization no longer meets the requirements of this part for being a contracting organization; • The MA organization commits or participates in fraudulent or abusive activities affecting the Medicare program, including submission of fraudulent data (as mentioned above, only DHHS/OIG can impose a CMP for this violation); • The MA organization experiences financial difficulties so severe that its ability to make necessary health services available is impaired to the point of posing an imminent and serious risk to the health of its enrollees, or otherwise fails to make services available to the extent that such a risk to health exists; • The MA organization substantially fails to comply with the requirements of the Federal Regulations at 42 CFR 422 Subpart M of this part relating to grievances and appeals; • The MA organization fails to provide CMS with valid data as required under Federal Regulations at 42 CFR 422.310; • The MA organization fails to implement an acceptable quality improvement program as required under Federal Regulations at 42 CFR 422 Subpart D of this part; • The MA organization substantially fails to comply with the prompt payment requirements in the Federal Regulations at 42 CFR 422.520; • The MA organization substantially fails to comply with the service access requirements in the Federal Regulations at 42 CFR 422.112 or the Federal Regulations at 42 CFR 422.114; • The MA organization fails to comply with the requirements of the Federal Regulations at 42 CFR 422.208 regarding physician incentive plans; or • The MA organization substantially fails to comply with the marketing requirements in the Federal Regulations at 42 CFR 422.80. CMS may impose CMPs for the reasons outlined at §422.510(a), other than fraud or abuse, if the deficiency on which the sanction determination is based has directly adversely affected (or has the substantial likelihood of adversely affecting) one or more MA enrollees. In such cases the amount of the CMS-imposed CMP is $25,000 for each determination. For each week that a deficiency remains uncorrected after the week in which the MA organization receives CMS's notice of the determination to impose a CMP, CMS may further impose CMPs in the amount of $10,000.