A physician or health care provider shall be debarred if it is
found, after appropriate investigation as described in Sec. 702.414 and
proceedings under Secs. 702.432 and 702.433, that such physician or
health care provider has:
(a) Knowingly and willfully made, or caused to be made, any false
statement or misrepresentation of a material fact for use in a claim for
compensation or claim for reimbursement of medical expenses under this
Act;
(b) Knowingly and willfully submitted, or caused to be submitted, a
bill or request for payment under this Act containing a charge which the
Director finds to be substantially in excess of the charge for the
service, appliance, or supply prevailing within the community or in
excess of the provider's customary charges, unless the Director finds
there is good cause for the bill or request containing the charge;
(c) Knowingly and willfully furnished a service, appliance, or
supply which is determined by the Director to be substantially in excess
of the need of the recipient thereof or to be of a quality which
substantially fails to meet professionally recognized standards;
(d) Been convicted under any criminal statute, without regard to
pending appeal thereof, for fraudulent activities in connection with
federal or state program for which payments are made to physicians or
providers of similar services, appliances, or supplies; or has otherwise
been excluded from participation in such program.
(e) The fact that a physician or health care provider has been
convicted of a crime previously described in (d), or excluded or
suspended, or has resigned in lieu of exclusion or suspension, from
participation in any program as described in (d), shall be a prima facie
finding of fact for purposes of section 7(j)(2) of the Act, 33 U.S.C.
907(j)(2).
[50 FR 404, Jan. 3, 1985]
