Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 46

Download a blank fillable Form Cms-855a - Medicare Enrollment Application - Institutional Providers in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Cms-855a - Medicare Enrollment Application - Institutional Providers with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SECTION 14: PENALTIES FOR FALSIFYING INFORMATION
This section explains the penalties for deliberately furnishing false information in this application
to gain or maintain enrollment in the Medicare program.
1. 18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within the
jurisdiction of any department or agency of the United States, knowingly and willfully falsifies,
conceals or covers up by any trick, scheme or device a material fact, or makes any false, fictitious,
or fraudulent statements or representations, or makes any false writing or document knowing the
same to contain any false, fictitious or fraudulent statement or entry. Individual offenders are subject
to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations
are subject to fines of up to $500,000 (18 U.S.C. § 3571). Section 3571(d) also authorizes fines
of up to twice the gross gain derived by the offender if it is greater than the amount specifically
authorized by the sentencing statute.
2. Section 1128B(a)(1) of the Social Security Act authorizes criminal penalties against any individual
who, “knowingly and willfully,” makes or causes to be made any false statement or representation
of a material fact in any application for any benefit or payment under a Federal health care program.
The offender is subject to fines of up to $25,000 and/or imprisonment for up to five years.
3. The Civil False Claims Act, 31 U.S.C. § 3729, imposes civil liability, in part, on any person who:
a) knowingly presents, or causes to be presented, to an officer or any employee of the United
States Government a false or fraudulent claim for payment or approval;
b) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false
or fraudulent claim paid or approved by the Government; or
c) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.
The Act imposes a civil penalty of $5,000 to $10,000 per violation, plus three times the amount of
damages sustained by the Government
4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person
(including an organization, agency or other entity) that knowingly presents or causes to be presented
to an officer, employee, or agent of the United States, or of any department or agency thereof, or of
any State agency…a claim…that the Secretary determines is for a medical or other item or service
that the person knows or should know:
a) was not provided as claimed; and/or
b) the claim is false or fraudulent.
This provision authorizes a civil monetary penalty of up to $10,000 for each item or service,
an assessment of up to three times the amount claimed, and exclusion from participation in the
Medicare program and State health care programs.
5. 18 U.S.C. 1035 authorizes criminal penalties against individuals in any matter involving a health
care benefit program who knowingly and willfully falsifies, conceals or covers up by any trick,
scheme, or device a material fact; or makes any materially false, fictitious, or fraudulent statements
or representations, or makes or uses any materially false fictitious, or fraudulent statement or
entry, in connection with the delivery of or payment for health care benefits, items or services. The
individual shall be fined or imprisoned up to 5 years or both.
CMS-855A (07/11)
45

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Medical
Form Cms-8550 - Medicare Enrollment Application Form Cms-8550 - Medicare Enrollment Application Medical
Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Medical
Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Medical
Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Medical
Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Medical
Form Cms-671 - Ltc Facility Application For Medicare/medicaid Form Cms-671 - Ltc Facility Application For Medicare/medicaid Medical
Form Cms-10069 - Medicare Waiver Demonstration Application Form Cms-10069 - Medicare Waiver Demonstration Application Medical
Medicare Enrolment Application Form Medicare Enrolment Application Form Medical
Form Cms-838 Medicare Credit Balance Report Certification Page Form Cms-838 Medicare Credit Balance Report Certification Page Medical

Related Categories

Parent category: Medical
Download
Go
Page of 54