Health Care Financing Administration--imposition of sanctions on health care practitioners and providers of health care services; program integrity. Final regulation.
These regulations establish procedures under which the Department may invoke sanctions against a practitioner or provider who furnishes or orders items or services which: (1) are not medically necessary; (2) do not meet professionally recognized standards; or (3) are not properly documented as to the medical necessity or quality of the services. The regulations also explain the role of the Medicaid State agency and establish the rights and responsibilities of the practitioner or provider, the Professional Standards Review Organization (PSRO), the Statewide Professional Standards Review Council, and the Health Care Financing Administration in this process. The regulations implement Section 1160 of the Social Security Act and apply to health care services for which payment may be made under that Act. The purpose of the sanction process is to discipline providers and practitioners where other corrective or educational effort have failed and to protect the public.
D005607:Fraud; D006296:Health Services / Q000331:legislation & jurisprudence*; D006300:Health Services Misuse / Q000331:legislation & jurisprudence*; D008484:Medicaid / Q000331:legislation & jurisprudence*; D006278:Medicare / Q000331:legislation & jurisprudence*; D011366:Professional Review Organizations / Q000331:legislation & jurisprudence*; D014481:United States