Medicare program; procedures for determining whether providers, practitioners, or other suppliers of services are...

These proposed regulations would revise the way we apply the limitation of liability provision under section 1879 of the Social Security Act (the Act). This proposal would preserve the provider's right to appeal a finding that the entity knew or could reasonably have been expected to know that a furnished service was not covered by Medicare. The proposal would not eliminate the limitation of liability for a provider that did not know services furnished were noncovered. We would make program payments when we determine that the provider and the beneficiary did not know and could not reasonably by have been expected to know that services were not covered. However, we would eliminate criteria that if met make a provider of Part A services eligible for a presumption that it should not be held liable. The decision to make or deny payment for noncovered services would be made after an analysis of the circumstances without the general assumption that the provider did not know or could not be expected to know that furnished services were noncovered. These proposed regulations also implement section 145 of the Tax Equity and Fiscal Responsibility Act of 1982 (Pub. L. 97-248). That section provides that a provider, practitioner or other supplier of services shall be deemed to have knowledge that payment cannot be made for certain noncovered items or services if the entity had been notified previously by the Secretary that a pattern of inappropriate utilization had occurred but has continued the practice after having a reasonable opportunity to correct the inappropriate utilization.