Page:United States Statutes at Large Volume 112 Part 3.djvu/534

 112 STAT. 2364 PUBLIC LAW 105-266—OCT. 19, 1998 to the provider's professional competence, professional performance, or financial integrity; or "(B) that surrendered such a license while a formal disciplinary proceeding was pending before such an authority, if the proceeding concerned the provider's professional competence, professional performance, or financial integrity. "(2) Any provider that is an entity directly or indirectly owned, or with a control interest of 5 percent or more held, by an individual who has been convicted of any offense described in subsection (b), against whom a civil monetary penalty has been assessed under subsection (d), or who has been debarred from participation under this chapter. "(3) Any individual who directly or indirectly owns or has a control interest in a semctioned entity and who knows or should know of the action constituting the basis for the entity's conviction of any offense described in subsection (b), assessment with a civil monetary penalty under subsection (d), or debarment from participation under this chapter. "(4) Any provider that the Office determines, in connection with claims presented under this chapter, has charged for health care services or supplies in an amount substantially in excess of such provider's customary charge for such services or supplies (unless the Office finds there is good cause for such charge), or charged for health care services or supplies which are substantially in excess of the needs of the covered individual or which are of a quality that fails to meet professionally recognized standards for such services or supplies. "(5) Any provider that the Office determines has committed acts described in subsection (d). Any determination under paragraph (4) relating to whether a charge for health care services or supplies is substantially in excess of the needs of the covered individual shall be made by trained reviewers based on written medical protocols developed by physicians. In the event such a determination cannot be made based on such protocols, a physician in an appropriate specialty shall be consulted."; (4) in subsection (d) (as so redesignated by paragraph (3)) by amending paragraph (1) to read as follows: "(1) in connection with claims presented under this chapter, that a provider has charged for a health care service or supply which the provider knows or should have known involves— "(A) an item or service not provided as claimed; "(B) charges in violation of applicable charge limitations under section 8904(b); or "(C) an item or service furnished during a period in which the provider was debarred from participation under this chapter pursuant to a determination by the Office under this section, other than as permitted under subsection (g)(2)(B);"; (5) in subsection (f) (as so redesignated by paragraph (3)) by inserting after "under this section" the first place it appears the following: "(where such debarment is not mandatory)"; (6) in subsection (g) (as so redesignated by paragraph (3))— (A) by striking "(g)(1)" and all that follows through the end of paragraph (1) and inserting the following:

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