Page:United States Statutes at Large Volume 86.djvu/1481

 86 STAT. ]

PUBLIC LAW 92-603-OCT. 30, 1972

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" (A) inpatient care is determined by such practitioner and by such hospital or other provider, consistent with professionally recognized health care standards, to be medically necessary for the proper care of such individual; and " (B)(i) the inpatient care required by such individual cannot, consistent with such standards, be provided more economically in a health care facility of a different type; or "(ii) (in the case of a patient who requires care which can, consistent with such standards, be provided more economically in a health care facility of a different type) there is, in the area in which such individual is located, no such facility or no such facility which is available to provide care to such individual at the time when care is needed by him. "(b)(1) If after reasonable notice and opportunity for discussion Report and with the practitioner or provider concerned, any Professional Stand- '•^^°"»'"«n'*^*i°"s ards Review Organization submits a report and recommendations to the Secretary pursuant to section 1157 (which report and recom- Ante, p. 1437. mendations shall be submitted through the Statewide Professional Standards Review Council, if such Council has been established, which shall promptly transmit such report and recommendations together with any additional comments and recommendations thereon as it deems appropriate) and if the Secretary determines that such practitioner or provider, in providing health care services over which such organization has review responsibility and for which payment (in whole or in part) may be made under this Act has— " (A) by failing, in a substantial number of cases, substantially to comply with any obligation imposed on him under subsection (a),or " (B) by grossly and flagranti}^ violating any such obligation in one or more instances, demonstrated an unwillingness or a lack of ability substantially to comply with such obligations, he (in addition to any other sanction provided under law) may exclude (permanently for such period as the Secretary may prescribe) such practitioner or provider from eligibility to provide such services on a reimbursable basis. "('2) A determination made by the Secretary under this subsection shall be effective at such time and upon such reasonable notice to the public and to the person furnishing the services involved as may be specified in regulations. Such determination shall be effective with respect to services furnished to an individual on or after the effective date of such determination (except that in the case of institutional •* health care servicer such determination shall be effective in the manner provided in title X VIII with respect to terminations of provider 42 USC 1395. agreements), and shall remain in effect until the Secretary finds and gives reasonable notice to the public that the basis for such determination has been removed and that there is reasonable assurance that it will not recur. " (3) In lieu of the sanction authorized by paragraph (1), the Secretary may require that (as a condition to the continued eligibility of such practitioner or provider to provide such health care services on a reimbursable basis) such practitioner or provider pay to the United States, in case such acts or conduct involved the provision or ordering by such practitioner or provider of health care services which were 5»i3i.a medically improper or unnecessary, an amount not in excess of the actual o;' estimated cost of the medically improper or unnecessary services so provided, or (if less) $5,000. Such amount may be deducted from any sums owing by the United States (or any instnimentality thereof) to the person from whom such amount is claimed.

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