CMS Pub. 100-08, ch. 4, § 4.11.5.1

The following is a brief description of authorities from the Social Security Act:

• Section 1806(b)(2)(B) - Any person or entity that fails to provide an itemized

statement describing each item or service requested by a Medicare beneficiary.

• Section 1833(h)(5)(D) - Any person billing for a clinical diagnostic laboratory

test, other than on an assignment-related basis. This provision includes tests

performed in a physician's office but excludes tests performed in a rural health

clinic. (This violation may also cause an assessment and an exclusion.)

• Section 1833(i)(6) - Any person billing for an intraocular lens inserted during or

after cataract surgery for which payment may be made for services in an

ambulatory surgical center.

• Section 1833(q)(2)(B) - When seeking payment on an unassigned basis, any

entity failing to provide information about a referring physician, including the

referring physician's name and unique physician identification number. (This

violation may also cause an exclusion.)

• Sections 1834(a)(11)(A) and 1842(j)(2) - Any supplier of durable medical

equipment charging for covered items (furnished on a rental basis) after the rental

payments may no longer be made (except for maintenance and servicing) as

provided in §1834(a)(7)(A) of the Act. (This violation may also cause an

assessment and an exclusion.)

• Section 1834(a)(17)(C) - Unsolicited telephone contacts by any supplier of

durable medical equipment to Medicare beneficiaries regarding the furnishing of

covered services. (This violation may only cause an exclusion.)

• Sections 1834(a)(18)(B) and 1842(j)(2) - Any durable medical equipment

supplier that fails to make a refund to Medicare beneficiaries for a covered item

for which payment is precluded due to an unsolicited telephone contact from the

supplier. (This violation may also cause an assessment and an exclusion.)

• Sections 1834(b)(5)(C) and 1842(j)(2) - Any non-participating physician or

supplier that charges a Medicare beneficiary more than the limiting charge as

specified in §1834(b)(5)(B) of the Act for radiologist services. (This violation

may also cause an assessment and an exclusion.)

• Sections 1834(c)(4)(C) and 1842(j)(2) - Any non-participating physician or

supplier charging a Medicare beneficiary more than the limiting charge for

mammography screening, as specified in §1834(c)(3) of the Act. (This violation

may also cause an assessment and an exclusion.)

• Sections 1834(h)(3) and 1842(j)(2) - Any supplier of durable medical equipment,

prosthetics, orthotics, and supplies charging for a covered prosthetic device,

orthotic, or prosthetic (furnished on a rental basis) after the rental payment may

no longer be made (except for maintenance and servicing). (This violation may

also cause an assessment and an exclusion.)

• Section 1834(h)(3) - Unsolicited telephone contacts by any supplier of durable

medical equipment, prosthetics, orthotics to Medicare beneficiaries regarding the

furnishing of prosthetic devices, orthotics, or prosthetics. (This violation may

only cause an exclusion.)

• Sections 1834(j)(4) and 1842(j)(2) - Any supplier of durable medical equipment,

prosthetics, orthotics, and supplies that fails to make refunds in a timely manner

to Medicare beneficiaries (for items or services billed on a non-assigned basis) if

the supplier does not possess a Medicare supplier number, if the item or service

is denied in advance, or if the item or service is determined not to be medically

necessary or reasonable. (This violation may also cause an assessment and an

exclusion.)

• Sections 1834(k)(6) and 1842(j)(2) - Any practitioner or other person that bills or

collects for outpatient therapy services or comprehensive outpatient rehabilitation

services on a non-assigned basis. (This violation may also cause an assessment

and an exclusion.)

• Section 1842(b)(18)(B) - For practitioners specified in §1842(b)(18)(C) of the

Act (physician assistants, nurse practitioners, clinical nurse specialists, certified

registered nurse anesthetists, certified nurse-midwives, clinical social workers,

and clinical psychologists), any practitioner billing (or collecting) for any

services on a non-assigned basis. (This violation may also cause an assessment

and an exclusion.)

• Section 1842(k) - Any physician presenting a claim or bill for an assistant at

cataract surgery performed on or after March 1, 1987. (This violation may also

cause an assessment and an exclusion.)

• Section 1842(l)(3) - Any non-participating physician who does not accept

payment on an assigned basis and who fails to refund beneficiaries for services

that are not reasonable or medically necessary or are of poor quality. (This

violation may also cause an assessment and an exclusion.)

• Section 1842(m)(3) - Any non-participating physician billing for an elective

surgical procedure on a non-assigned basis, who charges at least $500, fails to

disclose charge and coinsurance amounts to the Medicare beneficiary prior to

rendering the service, and fails to refund any amount collected for the procedure

in excess of the charges recognized and approved by the Medicare program.

(This violation may cause an assessment and an exclusion.)

• Section 1842(n)(3) - Any physician billing diagnostic tests in excess of the

scheduled fee amount. (This violation may cause an assessment and an

exclusion.)

• Section 1842(p)(3)(A) - Any physician that fails to promptly provide the

appropriate diagnosis code or codes upon request by CMS or a carrier on any

request for payment or bill submitted on a non-assigned basis.

• Section 1842(p)(3)(B) - Any physician failing to provide the diagnosis code or

codes after repeatedly being notified by CMS of the obligations on any request

for payment or bill submitted on a non-assigned basis. (This violation is only

subject to an exclusion.)

• Section 1848(g)(1)(B) - Any non-participating physician, supplier, or other

person who furnishes physicians' services and bills on a non-assigned basis, or

collects in excess of the limiting charge, or fails to make an adjustment or refund

to the Medicare beneficiary. (This violation may cause an assessment and an

exclusion.)

• Section 1848(g)(3) - Any person billing for physicians' services on a non-assigned basis for a Medicare beneficiary who is also eligible for Medicaid (these

individuals include qualified Medicare beneficiaries). This provision applies to

services furnished on or after April 1, 1990. (This violation may cause an

assessment and an exclusion.)

• Section 1848(g)(4) - Any physician, supplier, or other person (except one

excluded from the Medicare program) that fails to submit a claim for a

beneficiary within one year of providing the service; or imposes a charge for

completing and submitting the standard claims form. (This violation may cause

an exclusion.)

• Section 1862(b)(5)(C) - Any employer who (before October 1, 1998) fails to

provide an employee's group health insurance coverage information to the

Medicare contractor.

• Section 1862(b)(6)(B) - Any entity that fails to complete a claim form relating to

the availability of other health benefit plans, or provides inaccurate information

relating to the availability of other health plans on the claim form.

• Section 1877(g)(5) - Any person failing to report information concerning

ownership, investment, and compensation arrangements. (This violation may

cause an assessment and an exclusion.)

• Section 1879(h) - Any durable medical equipment supplier (including a supplier

of durable medical equipment, prosthetic devices, prosthetics, orthotics, and

supplies) failing to make refunds to Medicare beneficiaries for items or services

billed on an assigned basis if the supplier did not possess a Medicare supplier

number, if the item or service is denied in advance, or if the item or service is

determined to be not medically necessary or reasonable. (This violation may

cause an assessment and an exclusion.)

• Section 1882(a)(2) - Any person who issues a Medicare supplemental policy that

has not been approved by the state regulatory program or does not meet federal

standards. (This violation may cause an assessment and an exclusion.)

• Section 1882(p)(8) - Any person who sells or issues non-standard Medicare

supplemental policies. (This violation may cause an assessment and an

exclusion.)

• Section 1882(p)(9)(C) - Any person who sells a Medicare supplemental policy

and fails to make available the core group of basic benefits as part of its product

line; or fails to provide the individual (before the sale of the policy) an outline of

coverage describing the benefits provided by the policy. (This violation may

cause an assessment and an exclusion.)

• Section 1882(q)(5)(C) - Any person who fails to suspend a Medicare

supplemental policy at the policyholder's request (if the policyholder applies for

and is determined eligible for Medicaid); or to automatically reinstate the policy

as of the date the policyholder loses medical assistance eligibility (and the

policyholder provides timely notice of losing his or her Medicaid eligibility).

(This violation may cause an assessment and an exclusion.)

• Section 1882(r)(6)(A) - Any person that fails to refund or credit as required by the

supplemental insurance policy loss ratio requirements. (This violation may cause

an assessment and an exclusion.)

• Section 1882(s)(4) - Any issuer of a Medicare supplemental policy that does not

waive any time periods applicable to pre-existing conditions, waiting periods,

elimination periods, or probationary periods if the time periods were already

satisfied under a preceding Medicare policy; or denies a policy, conditions the

issuance or effectiveness of the policy, or discriminates in the pricing of the

policy based on health status or other criteria. (This violation may cause an

assessment and an exclusion.)

• Section 1882(t)(2) - Any issuer of a Medicare supplemental policy who fails to

provide medically necessary services to enrollees through the issuer's network of

entities; imposes premiums on enrollees in excess of the premiums approved by

the state; acts to expel an enrollee for reasons other than non-payment of

premiums; does not provide each enrollee at the time of enrollment with specific

information regarding policy restrictions; or fails to obtain a written

acknowledgment from the enrollee of receipt of the information. (This violation

may cause an assessment and an exclusion.)