CMS Pub. 100-08, ch. 4, § 4.11.5.2

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

Section 1128(a)(1)(A), (B) False or fraudulent claim for item or service

including incorrect coding (upcoding) or medically

unnecessary services.

Section 1128A(a)(1)(C) Falsely certified specialty.

Section 1128A(a)(1)(D) Claims presented by excluded party.

Section 1128A(a)(1)(E) Pattern of claims for unnecessary services or

supplies.

Section 1128A(a)(2) Assignment agreement, Prospective Payment

System (PPS) abuse violations.

Section 1128A(a)(3) PPS false/misleading information influencing

discharge decision.

Section 1128A(a)(4) Excluded party retaining ownership or controlling

interest in participating entity.

Section 1128A(a)(5) Remuneration offered to induce program

beneficiaries to use particular providers,

practitioners, or suppliers.

Section 1128A(a)(6) Contracting with an excluded individual.

Section 1128A(a)(7) Improper remuneration; i.e., kickbacks.

Section 1128A(b) Hospital physician incentive plans.

Section 1128A(b)(3) Physician falsely certifying medical necessity for

home health benefits.

Section 1128E(b) Failure to supply information on adverse action to

the Health Integrity and Protection Data Bank

(HIPDB).

Section 1140(b)(1) Misuse of Departmental symbols/emblems.

Section 1819(b)(3)(B)

Section 1919(b)(3)(B)

False statement in assessment of functional capacity

of skilled nursing facility (SNF) resident.

Section 1819(g)(2)(A)

Section 1919 (g)(2)(A)

Notice to SNF/nursing facility of standard scheduled

survey.

Section 1857(g)(1)(F) Managed care organization (MCO) fails to comply

with requirements of §1852(j)(3) or

§1852(k)(2)(A)(ii). (Prohibits MCO interference

with the provider's advice to an enrollee; mandates

that providers not affiliated with the MCO may not

bill or collect in excess of the limiting charge.)

Section 1860D-31(i)(3) Engaged in false or misleading marketing practices

under the Medicare prescription drug discount card

program; or overcharge prescription drug enrollees;

or misuse of transitional assistance funds.

Section 1862(b)(3)(c) Financial incentives not to enroll in a group health

plan.

Section 1866(g) Unbundling outpatient hospital costs.

Section 1867 Dumping by hospital/responsible physician of

patients needing emergency medical care.

Section 1876(i)(6)(A)(i)

Section 1903(m)(5)(A)(i)

Section 1857(g)(1)(A)

Failure by Health Maintenance Organization

(HMO)/competitive medical plan/MCO to provide

necessary care affecting beneficiaries.

Section 1876(i)(6)(A)(ii)

Section 1903(m)(5)(A)(ii)

Section 1857(g)(1)(B)

Premiums by HMO/competitive medical plan/MCO

in excess of permitted amounts.

Section 1876(i)(6)(A)(iii)

Section 1903(m)(5)(A)(iii)

Section 1857(g)(1)(C)

HMO/competitive medical plan/MCO

expulsion/refusal to re-enroll individual per

prescribed conditions.

Section 1876(i)(6)(A)(iv)

Section 1903(m)(5)(A)(iii)

Section 1857(g)(1)(D)

HMO/competitive medial plan/MCO practices to

discourage enrollment of individuals.

Section 1876(i)(6)(A)(v)

Section 1903(m)(5)(A)(iii)

Section 1857(g)(1)(E)

False or misrepresenting HMO/competitive medical

plan/MCO information to Secretary.

Section 1876(i)(6)(A)(vi)

Section 1903(m)(5)(A)(v)

Section 1857(f)

Failure by HMO/competitive medical plan/MCO to

assure prompt payment for Medicare risk-sharing

contracts only or incentive plan provisions.

Section 1876(i)(6)(A)(vii)

Section 1857(g)(1)(G)

HMO/competitive medical plan/MCO

hiring/employing person excluded under §1128 or

§1128A.

Section 1877(g)(3) Ownership restrictions for billing clinical lab

services.

Section 1877(g)(4) Circumventing ownership restriction governing

clinical labs and referring physicians.

Section 1882(d)(1) Material misrepresentation referencing compliance

of Medicare supplemental policies (including

Medicare + Choice).

Section 1882(d)(2) Selling Medicare supplemental policy (including

Medicare + Choice) under false pretense.

Section 1882(d)(3)(A) Selling health insurance that duplicates benefits.

Section 1882(d)(3)(B) Selling or issuing Medicare supplemental policy

(including Medicare + Choice) to a beneficiary

without obtaining a written statement from

beneficiary with regard to Medicaid status.

Section 1882(d)(4)(A) Use of mailings in the sale of non-approved

Medicare supplemental insurance (including

Medicare + Choice).

Section 1891(c)(1) Notifying home health agency of scheduled survey.

Section 1927(b)(3)(B) False information on drug manufacturer survey from

manufacturer/wholesaler/seller.

Section 1927(b)(3)(C) Provision of untimely or false information by drug

manufacturer with rebate agreement.

Section 1929(i)(3) Notifying home- and community-based care

providers/settings of survey.

Section 421(c) of the Health Care

Quality Improvement Act

(HCQIA)

Failure to report medical malpractice liability to

National Practitioner Data Bank.

Section 427(b) of HCQIA Breaching confidentiality of information report to

National Practitioner Data Bank.