Imposition of Sanctions on Health Care Practitioners and Providers of Health Care Services by a Quality Improvement Organization

Scope and definitions.

This section defines terms and scope for the imposition of sanctions on health care practitioners and providers by Quality Improvement Organizations.

Statutory obligations of practitioners and other persons.

It is the obligation of any health care practitioner or other person who furnishes or orders health care services that may be reimbursed under the Medicare or State health care programs to ensure, to the extent of his or her or its autho...

Acknowledgement and review of report.

The OIG reviews QIO reports and recommendations to determine if a violation occurred and whether to impose sanctions on a practitioner or provider.

Notice of sanction.

This provision outlines the OIG notification requirements for sanctioned practitioners and hospitals, including patient notification obligations and posting requirements.

Effect of an exclusion on program payments and services.

This provision establishes the impact of an exclusion on program payments and services by referencing the requirements in 42 CFR 1001.1901.

Reinstatement after exclusion.

This provision outlines the process for practitioners or entities to apply for reinstatement following an OIG exclusion.

Appeal rights.

This provision details the rights of practitioners and entities to request preliminary hearings, administrative reviews, and judicial reviews regarding OIG sanctions.

Sanctions.

This provision defines the types of sanctions, including exclusion and monetary assessments, that may be imposed on practitioners or providers.

Basic responsibilities.

This provision outlines the responsibilities of Quality Improvement Organizations (QIOs) in identifying, investigating, and reporting violations of practitioner obligations to the OIG.

Action on identification of a violation.

This provision mandates the specific notification and procedural steps a QIO must take when a violation of practitioner obligations is identified.

Meeting with a practitioner or other person.

This provision establishes the requirements for QIO panel composition and conduct during meetings with practitioners facing potential sanctions.

QIO finding of a violation.

This provision outlines the process for a QIO to affirm or modify its findings following a meeting with a practitioner and the requirements for subsequent corrective action.

QIO action on final finding of a violation.

This provision specifies the mandatory reporting requirements for a QIO when a violation remains unresolved, including notification to the OIG and state licensing boards.

QIO report to the OIG.

This provision details the required content and documentation for a QIO report submitted to the OIG when recommending sanctions against a practitioner.

Basis for recommended sanction.

This provision lists the factors a QIO must consider and document when recommending a sanction to the OIG.