CMS Pub. 100-04, ch. 30, § 140.10

Under §1842(1) of the Act, a physician who knowingly and willfully fails to make refund

within the time limits in §140.3 may be subject to sanctions (i.e., civil money penalties

and/or exclusion from the Medicare program). Generally, the failure of a physician to

make a refund comes to the contractor’s attention as a result of a beneficiary complaint to

the contractor, Social Security Administration (SSA), or CMS. If necessary, the

contractor will contact the beneficiary to clarify the information in the complaint and to

determine the amount the beneficiary paid the physician for the denied services. If the

contractor determines that a physician failed to make a refund, it will contact the

physician in person or by telephone to discuss the facts of the case. The contractor will

attempt to determine why the amounts collected have not been refunded and will explain

that the law requires that the physician make refund to the beneficiary and that if he/she

fails to do so, the OIG may impose civil money penalties and assessments, and sanctions.

The contractor will make a dated report of contact and include the information relayed to

the physician and the physician’s response. The contractor will recontact the beneficiary

in 15 days to determine whether the refund has been made. When the amount in question

is $300 or more or where there are at least three outstanding violations by the physician,

the contractor will contact the Sanctions Coordinator in the appropriate field office of the

OIG by telephone to discuss whether referral to OIG is appropriate. If the case should be

referred, the contractor will make the referral to the regional OIG Sanctions Coordinator

in accordance with the procedures following. The contractor should not make a referral

until the physician’s appeal rights have been exhausted, or until the time limit for an

appeal has passed.