Civil Monetary Penalties Delegated to OIG

4.11.5.2 - Civil Monetary Penalties Delegated to OIG (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) The following is a brief description of authorities from the Social Security Act: Section 1128(a)(1)(A), (B) False or fraudulent claim for item or service including incorrect coding (upcoding) or medically unnecessary services. Section 1128A(a)(1)(C) Falsely certified specialty. Section 1128A(a)(1)(D) Claims presented by excluded party. Section 1128A(a)(1)(E) Pattern of claims for unnecessary services or supplies. Section 1128A(a)(2) Assignment agreement, Prospective Payment System (PPS) abuse violations. Section 1128A(a)(3) PPS false/misleading information influencing discharge decision. Section 1128A(a)(4) Excluded party retaining ownership or controlling interest in participating entity. Section 1128A(a)(5) Remuneration offered to induce program beneficiaries to use particular providers, practitioners, or suppliers. Section 1128A(a)(6) Contracting with an excluded individual. Section 1128A(a)(7) Improper remuneration; i.e., kickbacks. Section 1128A(b) Hospital physician incentive plans. Section 1128A(b)(3) Physician falsely certifying medical necessity for home health benefits. Section 1128E(b) Failure to supply information on adverse action to the Health Integrity and Protection Data Bank (HIPDB). Section 1140(b)(1) Misuse of Departmental symbols/emblems. Section 1819(b)(3)(B) Section 1919(b)(3)(B) False statement in assessment of functional capacity of skilled nursing facility (SNF) resident. Section 1819(g)(2)(A) Section 1919 (g)(2)(A) Notice to SNF/nursing facility of standard scheduled survey. Section 1857(g)(1)(F) Managed care organization (MCO) fails to comply with requirements of §1852(j)(3) or §1852(k)(2)(A)(ii). (Prohibits MCO interference with the provider's advice to an enrollee; mandates that providers not affiliated with the MCO may not bill or collect in excess of the limiting charge.) Section 1860D-31(i)(3) Engaged in false or misleading marketing practices under the Medicare prescription drug discount card program; or overcharge prescription drug enrollees; or misuse of transitional assistance funds. Section 1862(b)(3)(c) Financial incentives not to enroll in a group health plan. Section 1866(g) Unbundling outpatient hospital costs. Section 1867 Dumping by hospital/responsible physician of patients needing emergency medical care. Section 1876(i)(6)(A)(i) Section 1903(m)(5)(A)(i) Section 1857(g)(1)(A) Failure by Health Maintenance Organization (HMO)/competitive medical plan/MCO to provide necessary care affecting beneficiaries. Section 1876(i)(6)(A)(ii) Section 1903(m)(5)(A)(ii) Section 1857(g)(1)(B) Premiums by HMO/competitive medical plan/MCO in excess of permitted amounts. Section 1876(i)(6)(A)(iii) Section 1903(m)(5)(A)(iii) Section 1857(g)(1)(C) HMO/competitive medical plan/MCO expulsion/refusal to re-enroll individual per prescribed conditions. Section 1876(i)(6)(A)(iv) Section 1903(m)(5)(A)(iii) Section 1857(g)(1)(D) HMO/competitive medial plan/MCO practices to discourage enrollment of individuals. Section 1876(i)(6)(A)(v) Section 1903(m)(5)(A)(iii) Section 1857(g)(1)(E) False or misrepresenting HMO/competitive medical plan/MCO information to Secretary. Section 1876(i)(6)(A)(vi) Section 1903(m)(5)(A)(v) Section 1857(f) Failure by HMO/competitive medical plan/MCO to assure prompt payment for Medicare risk-sharing contracts only or incentive plan provisions. Section 1876(i)(6)(A)(vii) Section 1857(g)(1)(G) HMO/competitive medical plan/MCO hiring/employing person excluded under §1128 or §1128A. Section 1877(g)(3) Ownership restrictions for billing clinical lab services. Section 1877(g)(4) Circumventing ownership restriction governing clinical labs and referring physicians. Section 1882(d)(1) Material misrepresentation referencing compliance of Medicare supplemental policies (including Medicare + Choice). Section 1882(d)(2) Selling Medicare supplemental policy (including Medicare + Choice) under false pretense. Section 1882(d)(3)(A) Selling health insurance that duplicates benefits. Section 1882(d)(3)(B) Selling or issuing Medicare supplemental policy (including Medicare + Choice) to a beneficiary without obtaining a written statement from beneficiary with regard to Medicaid status. Section 1882(d)(4)(A) Use of mailings in the sale of non-approved Medicare supplemental insurance (including Medicare + Choice). Section 1891(c)(1) Notifying home health agency of scheduled survey. Section 1927(b)(3)(B) False information on drug manufacturer survey from manufacturer/wholesaler/seller. Section 1927(b)(3)(C) Provision of untimely or false information by drug manufacturer with rebate agreement. Section 1929(i)(3) Notifying home- and community-based care providers/settings of survey. Section 421(c) of the Health Care Quality Improvement Act (HCQIA) Failure to report medical malpractice liability to National Practitioner Data Bank. Section 427(b) of HCQIA Breaching confidentiality of information report to National Practitioner Data Bank.