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Code of Federal Regulations (Last Updated: May 6, 2024) |
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Title 42 - Public Health |
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Chapter V - Office of Inspector General-Health Care, Department of Health and Human Services |
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SubChapter B - OIG Authorities |
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Part 1003 - Civil Money Penalties, Assessments and Exclusions |
§ 1003.103 - Amount of penalty.
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§ 1003.103 Amount of penalty.
(a) Except as provided in paragraphs (b) through (k) of this section, the OIG may impose a penalty of not more than -
(1) $2,000[1] for each wrongful act occurring before January 1, 1997 that is subject to a determination under § 1003.102; and
(2) $10,000[2] for each wrongful act occurring on or after January 1, 1997 that is subject to a determination under § 1003.102.
(b) The OIG may impose a penalty of not more than $15,000[3] for each person with respect to whom a determination was made that false or misleading information was given under § 1003.102(b)(4), or for each item and service that is subject to a determination under § 1003.102(a)(5) or § 1003.102(b)(9) of this part. The OIG may impose a penalty of not more than $100,000[4] for each arrangement or scheme that is subject to a determination under § 1003.102(b)(10) of this part.
(c) The OIG may impose a penalty of not more than $10,000[5] for each payment for which there was a failure to report required information in accordance with § 1003.102(b)(5), or for each improper disclosure, use or access to information that is subject to a determination under § 1003.102(b)(6).
(d)
(1) The OIG may impose a penalty of not more than $5,000[6] for each violation resulting from the misuse of Departmental, CMS, Medicare or Medicaid program words, letters, symbols or emblems as described in § 1003.102(b)(7) relating to printed media, and a penalty of not more than $25,000[7] in the case of such misuse related to a broadcast or telecast, that is related to a determination under § 1003.102(b)(7).
(2) For purposes of this paragraph, a violation is defined as -
(i) In the case of a direct mailing solicitation or advertisement, each separate piece of mail which contains one or more words, letters, symbols or emblems related to a determination under § 1003.102(b)(7);
(ii) In the case of a printed solicitation or advertisement, each reproduction, reprinting or distribution of such item related to a determination under § 1003.102(b)(7); and
(iii) In the case of a broadcast or telecast, each airing of a single commercial or solicitation related to a determination under § 1003.102(b)(7).
(e) For violations of section 1867 of the Act or § 489.24 of this title, the OIG may impose -
(1) Against each participating hospital with an emergency department, a penalty of not more than $50,000[8] for each negligent violation occurring on or after May 1, 1991, except that if the participating hospital has fewer than 100 State-licensed, Medicare-certified beds on the date the penalty is imposed, the penalty will not exceed $25,000[9] ; and
(2) Against each responsible physician, a penalty of not more than $50,000[10] for each negligent violation occurring on or after May 1, 1991.
(f)
(1) The OIG may, in addition to or in lieu of other remedies available under law, impose a penalty of up to $25,000[11] for each determination by CMS that a contracting organization has -
(i) Failed substantially to provide an enrollee with required medically necessary items and services and the failure adversely affects (or has the likelihood of adversely affecting) the enrollee;
(ii) Imposed premiums on enrollees in excess of amounts permitted under section 1876 or title XIX of the Act;
(iii) Acted to expel or to refuse to re-enroll a Medicare beneficiary in violation of the provisions of section 1876 of the Act and for reasons other than the beneficiary's health status or requirements for health care services;
(iv) Misrepresented or falsified information furnished to an individual or any other entity under section 1876 or section 1903(m) of the Act;
(v) Failed to comply with the requirements of section 1876(g)(6)(A) of the Act, regarding prompt payment of claims; or
(vi) Failed to comply with the requirements of § 417.479 (d) through (i) of this title for Medicare, and § 417.479 (d) through (g) and (i) of this title for Medicaid, regarding certain prohibited incentive payments to physicians.
(2) The OIG may, in addition to or in lieu of other remedies available under law, impose a penalty of up to $25,000[12] for each determination by CMS that a contracting organization with a contract under section 1876 of the Act -
(i) Employs or contracts with individuals or entities excluded, under section 1128 or section 1128A of the Act, from participation in Medicare for the provision of health care, utilization review, medical social work, or administrative services; or
(ii) Employs or contracts with any entity for the provision of services (directly or indirectly) through an excluded individual or entity.
(3) The OIG may, in addition to or in lieu of other remedies available under law, impose a penalty of up to $100,000[13] for each determination that a contracting organization has -
(i) Misrepresented or falsified information to the Secretary under section 1876 of the Act or to the State under section 1903(m) of the Act; or
(ii) Acted to expel or to refuse to re-enroll a Medicaid beneficiary because of the individual's health status or requirements for health care services, or engaged in any practice that would reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by section 1876 or section 1903(m) of the Act) with the contracting organization by Medicare beneficiaries and Medicaid beneficiaries whose medical condition or history indicates a need for substantial future medical services.
(4) If enrolles are charged more than the allowable premium, the OIG will impose an additional penalty equal to double the amount of excess premium charged by the contracting organization. The excess premium amount will be deducted from the penalty and returned to the enrollee.
(5) The OIG will impose an additional $15,000[14] penalty for each individual not enrolled when CMS determines that a contracting organization has committed a violation described in paragraph (f)(3)(ii) of this section.
(6) For purposes of paragraph (f) of this section, a violation is each incident where a person has committed an act listed in § 417.500(a) or § 434.67(a) of this title, or failed to comply with a requirement set forth in § 434.80(c) of this title.
(g) The OIG may impose a penalty of not more than $25,000[15] against a health plan for failing to report information on an adverse action required to be reported to the Healthcare Integrity and Protection Data Bank in accordance with section 1128E of the Act and § 1003.102(b)(5)(ii).
(h) For each violation of § 1003.102(b)(11), the OIG may impose -
(1) A penalty of not more than $50,000[16] , and
(2) An assessment of up to three times the total amount of remuneration offered, paid, solicited or received, as specified in § 1003.104(b).
(i) For violations of § 1003.102(b)(14) of this part, the OIG may impose a penalty of not more than the greater of -
(1) $5,000[17] , or
(2) Three times the amount of Medicare payments for home health services that are made with regard to the false certification of eligibility by a physician in accordance with sections 1814(a)(2)(C) or 1835(a)(2)(A) of the Act.
(j) The OIG may impose a penalty of not more than $10,000[18] per day for each day that the prohibited relationship described in § 1001.102(b)(12) of this part occurs.
(k) For violations of section 1862(a)(14) of the Act and § 1003.102(b)(15), the OIG may impose a penalty of not more than $2,000[19] for each bill or request for payment for items and services furnished to a hospital patient.
(l) For violations of section 351A(b) or (c) of the Public Health Service Act and 42 CFR part 73, the OIG may impose a penalty of not more than $250,000[20] in the case of an individual, and not more than $500,000[21] in the case of any other person.
(m) For violations of section 1860D-31 of the Act and 42 CFR part 403, subpart H, regarding the misleading or defrauding of program beneficiaries, or the misuse of transitional assistance funds, the OIG may impose a penalty of not more than $10,000[22] for each individual violation.
[57 FR 3346, Jan. 29, 1992, as amended at 59 FR 32125, June 22, 1994; 59 FR 48566, Sept. 22, 1994; 60 FR 16584, Mar. 31, 1995; 60 FR 58241, Nov. 27, 1995; 61 FR 13449, Mar. 27, 1996; 61 FR 52301, Oct. 7, 1996; 64 FR 39429, July 22, 1999; 65 FR 18550, Apr. 7, 2000; 65 FR 24416, Apr. 26, 2000; 65 FR 35584, June 5, 2000; 67 FR 76905, Dec. 13, 2002; 69 FR 28845, May 19, 2004; 81 FR 61564, Sept. 6, 2016]