C.F.R. » Title 42 » CHAPTER V—OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—OIG AUTHORITIES › PART 1004—IMPOSITION OF SANCTIONS ON HEALTH CARE PRACTITIONERS AND PROVIDERS OF HEALTH CARE SERVICES BY A QUALITY IMPROVEMENT ORGANIZATION › Subpart C—QIO Responsibilities

42 C.F.R. § 1004.80

QIO report to the OIG

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(a) Manner of reporting. If the violation(s) identified by the QIO have not been resolved, it must submit a report and recommendation to the OIG at the field office with jurisdiction.

(b) Content of report. The QIO report must include the following information—

(1) Identification of the practitioner or other person and, when applicable, the name of the director, administrator or owner of the entity involved;

(2) The type of health care services involved;

(3) A description of each failure to comply with an obligation, including specific dates, places, circumstances and other relevant facts;

(4) Pertinent documentary evidence;

(5) Copies of written correspondence, including reports of conversations with the practitioner or other person regarding the violation and, if applicable, a copy of the verbatim transcript of the meeting with the practitioner or other person;

(6) The QIO's finding that an obligation under section 1156(a) of the Act has been violated and that the violation is substantial and has occurred in a substantial number of cases or is gross and flagrant;

(7) A case-by-case analysis and evaluation of any additional information provided by the practitioner or other person in response to the QIO's initial finding;

(8) A copy of the CAP that was developed and documentation of the results of such plan;

(9) The number of admissions by the practitioner or other person reviewed by the QIO during the period in which the violation(s) were identified;

(10) The professional qualifications of the QIO's reviewers; and

(11) The QIO's sanction recommendation.

(c) QIO recommendation. The QIO must specify in its report—

(1) The sanction recommended;

(2) The amount of the monetary penalty recommended, if applicable;

(3) The period of exclusion recommended, if applicable;

(4) The availability of alternative sources of services in the community, with supporting information; and

(5) The county or counties in which the practitioner or other person furnishes services.

[60 FR 63640, Dec. 12, 1995, as amended at 62 FR 23143, Apr. 29, 1997]
Notes of Decisions
Cited in 4 cases, 1987–1988 · leading case: Doyle v. Bowen, 660 F. Supp. 1484 (D. Me. 1987).
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Doyle v. Bowen, 660 F. Supp. 1484 (D. Me. 1987). · cites it 2× “*1491 42 C.F.R. § 1004.80 (emphasis added). 7 The Court concludes that HCRI failed to base its recommendation of a five-year sanction on a consideration of these factors and that, therefore, the sanction is invalid.”
Lavapies v. Bowen, 687 F. Supp. 1193 (S.D. Ohio 1988). “42 C.F.R. § 1004.80 . A copy of the PRO report sent to the OIG must also be sent to the affected practitioner along with a notice informing him or her that the recommendation has been submitted and that he or she has 30 days to submit any additional material to the OIG.”
Papendick v. Bowen, 658 F. Supp. 1425 (W.D. Wis. 1987). “42 C.F.R. § 1004.80 . A copy of the PRO report sent to the OIG must also be sent to the affected practitioner along with a notice informing him or her that the recommendation has been submitted and that he or she has 30 days to submit any additional material to the OIG.”
Doyle v. Sec'y of Health & Human Servs., 848 F.2d 296 (1st Cir. 1988). “42 C.F.R. § 1004.80 (1987). (At the time of Dr.”
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