[Federal Register Volume 60, Number 62 (Friday, March 31, 1995)]
[Rules and Regulations]
[Pages 16580-16584]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-7845]



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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of Inspector General

42 CFR Part 1003

RIN 0991-AA65


Civil Money Penalties for Referrals to Entities and for 
Prohibited Arrangements and Schemes

AGENCY: Office of Inspector General (OIG), HHS.

ACTION: Final rule with comment period.

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SUMMARY: This final rule implements the civil money penalty (CMP) 
provisions established through sections 1877(g)(3) and 1877(g)(4) of 
the Social Security Act. Specifically, in accordance with section 
1877(g)(3), these regulations set forth CMPs, assessments and an 
exclusion against any person who presents, or causes to be presented, a 
bill or claim the person knows or should know is for a service 
unlawfully referred under section 1877(a)(1)(A) of the Act, or has not 
refunded amounts inappropriately collected for a prohibited referral. 
In addition, in accordance with section 1877(g)(4), these regulations 
set forth CMPs, assessments and an exclusion in cases where a physician 
or entity enters into an arrangement or scheme in which the physician 
or entity knows, or should have known, that the principal purpose is to 
assure referrals by the physician which, if made directly to a 
particular entity, would violate the prohibition on referrals described 
in section 1877(a) of the Act.

DATES: Effective date: This final rule with comment period is effective 
on March 31, 1995.
    Comment period: Comments on the applicability of these CMPs for 
referrals to ``designated health services'' resulting from provisions 
in the Omnibus Budget Reconciliation Act (OBRA) of 1993 will 
[[Page 16581]] be considered if we receive them at the address 
specified below, no later than 5 p.m. on May 30, 1995. Broadening these 
CMPs to cover referrals to ``designated health services'' is discussed 
in sections I.C. and IV. of this preamble. We will not consider 
comments on provisions that remain unchanged from the October 20, 1993 
proposed rule or on provisions that were changed based on public 
comments.

ADDRESSES: Mail comments to: Office of Inspector General, Department of 
Health and Human Services, Attention: LRR-30-FC, Room 5246, 330 
Independence Avenue SW., Washington, DC 20201.
    If you prefer, you may deliver your comments to Room 5551, 330 
Independence Avenue, SW., Washington DC 20201. Because of staffing and 
resource limitations, we cannot accept comments by facsimile (FAX) 
transmission. In commenting, please refer to file code LRR-30-FC. 
Comments received timely will be available for public inspection as 
they are received, generally beginning approximately 3 weeks after 
publication of this document, in room 5551, 330 Independence Avenue 
SW., Washington, DC on Monday through Friday of each week from 8:30 
a.m. to 5 p.m., (202) 619-3270.

FOR FURTHER INFORMATION CONTACT:
Joel Schaer, Legislation, Regulations and Public Affairs Staff, (202) 
619-3270.

SUPPLEMENTARY INFORMATION:

I. Background

A. The Omnibus Budget Reconciliation Acts of 1989 and 1990

    In an effort to limit physician referrals involving laboratory 
services, section 6204 of Pub. L. 101-239, the Omnibus Budget 
Reconciliation Act (OBRA) of 1989, as amended by section 4207(e) of 
Pub. L. 101-508 (OBRA of 1990), added a new section 1877--Limitations 
on Certain Physician Referrals--to the Social Security Act.
    As set forth by OBRA 1989 and 1990, section 1877, with certain 
exceptions, prohibited a physician from making a referral to an entity 
for the furnishing of clinical laboratory services for which Medicare 
would otherwise pay, if the physician or a member of the physician's 
immediate family had a financial relationship with that entity. (See 
the discussion in section I.C. below regarding expansion of this 
authority to ``designated health services'' as a result of amendments 
set forth in OBRA 1993.) This provision further prohibited an entity 
from presenting, or causing to be presented, a Medicare claim or bill 
to any individual, third party payer or other entity for laboratory 
services furnished in accordance with a prohibited referral. The 
authority for implementing these provisions is a bifurcated 
responsibility between the Health Care Financing Administration (HCFA) 
and the OIG. The HCFA has had the responsibility for developing 
regulations that set forth the specific policies by which such 
prohibited conduct is defined, while the OIG has maintained 
responsibility for imposing civil money penalties (CMPs), assessments 
and program exclusions for violations of this referral ban.

B. Proposed HCFA and OIG Regulations

    On March 11, 1992, the HCFA issued proposed regulations (57 FR 
8588) setting forth provisions that would--(1) with certain specified 
exceptions, prohibit a physician from making a referral to an entity 
for the furnishing of laboratory services for which Medicare would 
otherwise pay, if the physician or a member of his or her immediate 
family has a financial relationship with that entity; and (2) prohibit 
an entity from presenting or causing to be presented a Medicare claim 
or bill for such services furnished in accordance with that referral. 
Because the statute was quite detailed in scope, the HCFA proposed rule 
adhered closely to the statutory language and adopted--with little 
change--several definitions, such as the definition of prohibited 
financial relationships and compensation arrangements.
    In addition, on October 20, 1993 the OIG issued a proposed rule (58 
FR 54096) that was designed to codify the penalty provisions of the 
statute set forth in sections 1877 (g)(3) and (g)(4) of the Social 
Security Act. The proposed rule addressed the establishment of CMPs of 
not more than $15,000 for each violation of the ban on making claims 
for services resulting from prohibited referrals or failing to make a 
refund, and CMPs of not more than $100,000 for physicians and entities 
who engage in a circumvention scheme to avoid detection of prohibited 
referrals.

C. The Omnibus Budget Reconciliation Act of 1993

    The Omnibus Budget Reconciliation Act of 1993 expanded the scope of 
section 1877 of the Act to extend the prohibition to Medicare and 
Medicaid referrals beyond clinical laboratory service to include 
various ``designated health services.'' Specifically, OBRA 1993 amended 
the Medicaid payment provisions by adding a new section 1903(s) to 
state that no payments are to be made to a State for services furnished 
by designated health services that violate the referral prohibitions of 
section 1877. The provision is also applicable to the reporting and 
penalty provisions under sections 1877(f) and (g)(5) of the Act. The 
designated health services cover both diagnostic services and 
therapeutic items and services, including physical and occupational 
therapy services; radiology services; radiation therapy services and 
supplies; durable medical equipment (DME) and supplies; parenteral and 
enteral nutrients, equipment and supplies; prosthetics, orthotics and 
prosthetic devices and supplies; home health services; outpatient 
prescription drugs; and inpatient and outpatient hospital services.
    These expansions resulting from OBRA 1993--the expansion to 
Medicaid to be effective beginning on December 31, 1994, and the 
expansion to other designated health services to be effective for 
referrals made after December 31, 1994--were not incorporated into 
either the HCFA or OIG proposed rules summarized above. The HCFA 
intends to publish new proposed regulations--separate from the final 
rule addressing physician ownership of, and referrals to, entities that 
furnish clinical laboratory services--that will (1) cover how the 
referral prohibition applies to additional services now covered by 
section 1877 as the result of OBRA 1993, (2) explain various new 
exceptions added to the statute, and (3) define key terms such as 
financial relationship, inpatient/outpatient services, diagnostic 
services and DME.
    However, because the penalty provisions set forth in sections 1877 
(g)(3) and (g)(4) of the Act remain unchanged by these amendments, we 
are incorporating by reference the expansion to designated health 
services into our final rulemaking for sanctioning improper claims and 
circumvention schemes. Since the statutory changes associated with 
these penalty provisions are self-implementing, we believe that the 
regulatory revisions set forth in this rulemaking can be implemented 
without interpretation and that public comment would not substantially 
modify these regulations. We believe that affording additional proposed 
rulemaking under these circumstances is unnecessary and would delay the 
promulgation of regulations that correspond with the current statute. 
Therefore, we find good cause to waive proposed rulemaking for 
incorporating the statutory expansion to designated health services by 
reference into our final rulemaking. However, we are providing a 60-day 
comment period for [[Page 16582]] comments limited to the area of 
designated health services in order to give parties now covered by 
these CMP regulations as providers of designated health services an 
opportunity to make applicable comments. Although these regulations are 
being issued as a final rule, any additional comments will be 
considered for possible future amendments to the rulemaking, where 
appropriate.

II. Provisions of the OIG Proposed Rule

    The OIG proposed regulations, published in the Federal Register on 
October 20, 1993, provided for a penalty against any person presenting 
a bill or claim to be paid by Medicare for services furnished under a 
``self-referral'' arrangement prohibited under section 1877(a) of the 
Act, or any person failing to refund amounts that were inappropriately 
billed and collected as the result of a prohibited referral. The 
proposed regulations established--
     A CMP of no more than $15,000 for each service provided in 
accordance with a prohibited referral, for which a bill or claim was 
presented, or caused to be presented, or caused to be presented, or 
which was not properly refunded;
     An assessment of not more than twice the amount claimed 
for each service that was the basis for the CMP; and
     An exclusion of the individual from Medicare and State 
health care program participation.
    In determining the amount of penalty and assessment for this 
violation, the proposed rule specified that the OIG would apply the 
five existing criteria set forth in Sec. 1003.106(a) of the 
regulations, and proposed a sixth criterion to be applied to consider 
timeliness and completeness with respect to the appropriate refund(s).
    In addition, the proposed regulations provided for a penalty 
against a physician or entity entering into an agreement or 
``circumvention'' scheme to assure referrals which, if they were made 
directly, would violate the prohibition on referrals set out in section 
1877(a) of the Act. One example of such a scheme would be a cross-
referral arrangement where the physician owners of two different 
entities refer to each other. The proposed regulations established--
     A CMP of not more than $100,000 for each arrangement or 
circumvention scheme entered into by a physician or entity;
     An assessment of not more than twice the amount claimed by 
the physician or entity for each service billed under the prohibited 
arrangement; and
     An exclusion of the physician or entity form Medicare and 
State health care program participation.
    In determining the amount of the penalty and assessment for this 
violation, the proposed rule specified that the OIG would apply the 
five existing criteria in Sec. 1003.106(a) of the regulations, and 
proposed an additional criterion that would consider the amount of 
ownership interests involved.

III. Response to the Public Comments

    In response to this proposed rule, the OIG received a total of five 
timely-filed public comments from associations and individuals. Set 
forth below is a summary of those comments received and our response to 
the various concerns they raised.

Definition of ``Timely Basis''

    Comment: Proposed Sec. 1003.102(b)(8) stated that the OIG may 
impose a penalty against any person ``who has not refunded on a timely 
basis amounts collected as a result of billing an individual, third 
party payer or other entity for a clinical laboratory service that was 
provided in accordance with a prohibited referral * * *'' (underlining 
added). The commenter believes that providers should be made aware of 
any time requirements to which they will be held accountable, and 
recommends that we define the term ``timely basis.''
    Response: We agree with the commenter that this term should be 
clarified, and are defining ``timely basis'' in Sec. 1003.101 of the 
regulations as the 60 day period from the time the prohibited amounts 
are collected. We believe that there is precedent for defining this 
time period.
    Currently, the general government refund policy for overpayments is 
30 days. For example, section 1815(d) of the Social Security Act--
addressing payments to providers under part A of the Medicare program--
requires a refund (or offset) of excess payments within 30 days of a 
final determination that the amount of payment was in excess of the 
amount due. However, the 30 days begins to run after a final 
determination is made that there was an overpayment, while 
Sec. 1003.102(b)(8) of our regulations contemplates that the person who 
collected amounts for a service provided in accordance with a 
prohibited referral will take the initiative to refund those amounts on 
a timely basis without first being subject to a ``final 
determination.''
    The HCFA regulations at 42 CFR 411.24(h) seem more analogous to the 
``refund'' provision addressed in these penalty provisions than to the 
overpayment time periods. These HCFA Medicare secondary payer 
regulations require a beneficiary or other party who receives a third 
party payment to reimburse Medicare within 60 days. Under 411.24(h), 
the recipient of the third party payment is expected to take the 
initiative to refund the program, without first receiving notice, or 
having a ``determination'' by HCFA that the refund is required. Since 
the OIG regulations intend for persons who profit from prohibited 
referrals to initiate making the refund, we believe that a 60 day 
period is a reasonable time period to establish is defining ``timely 
basis.''

Clarifying the Scope of the Regulations

    Comment: One commenter asked that we clarify the regulations text 
to specify, as we did in the preamble to the proposed rule, that 
physicians--as well as the laboratory (or designated health service 
provider)--may be subject to CMPs for causing the submission of claims 
for services resulting from prohibited referrals.
    Response: We believe that the language set forth in Sec. 1003.102 
is adequate to cover the scope of these provisions. The word ``person'' 
as defined in Sec. 1003.101 includes an individual, trust, estate, 
partnership, corporation, professional association or corporation, or 
other entity. Physicians, as ``individuals,'' are specifically included 
under this definition.

Criteria for Circumvention Scheme Sanctions

    Comment: The rulemaking proposed adding a new criterion in 
Sec. 1003.106(a) that would take into account the amount of ownership 
interests involved when determining penalty amounts or assessments for 
circumvention schemes. One commenter strongly supported this criterion 
of requiring providers to disclose the amount of ownership interest 
whenever making an ownership disclosure under section 1877 rather than 
just the fact of ownership interest in a facility.
    Response: We appreciate the commenter's support of this additional 
criterion, and believe that requiring the provider to disclose the 
amount of ownership will act as a further deterrent to providers 
referring patients to facilities in which they have financial 
interests.
    Comment: In referencing both Sec. 1003.102(b)(9) of the proposed 
regulations and existing Sec. 1003.102(c), one commenter raised 
concerns regarding the ability of outside third parties to effectively 
counsel [[Page 16583]] practitioners if such counseling activities were 
considered subject to penalties as part of a ``circumvention'' scheme. 
The commenter expressed concern that the regulation would discourage 
lawyers, accountants and other professionals from advising physicians 
on how to set up practices for fear that the advising professional 
would be ``adding and abetting'' a violation.
    Response: This regulation is directed specifically at physicians 
and entities that enter into a ``cross-referral arrangement'' or a 
scheme which the physician or entity knows or should know is designed 
to circumvent the prohibitions of this provision. It should in no way 
discourage physicians from seeking professional advice in good faith, 
or discourage attorneys and accountants from giving such advice in good 
faith.

Resource Issues

    Comment: One commenter took issue with the regulatory impact 
statement that states the rulemaking will have no direct effect on the 
economy or on Federal or State expenditures. The commenter believes 
that there will be a considerable increase in the workload of Medicare 
auditors and fraud units in their efforts to detect fraud and abuse, 
and believes that the impact statement should reflect these increased 
activities.
    In addition, based on information a second commenter is currently 
receiving on physician ownership of other entities when individuals are 
requesting provider numbers, the commenter indicated that they would 
need to establish specific flags or edits to be adequately apprised of 
situations involving potential violations.
    Response: We do not believe that these penalty provisions will 
result in significantly increased expenditures for detection efforts in 
this area, and believe that these concerns do not warrant altering the 
existing regulatory impact statement. While we do not anticipate 
funding levels to significantly increase as a result of this additional 
authority, we remain acutely aware of the issue and need for resources 
in general, and will continue to invite and rely on active 
participation from within the health care industry to aid in efforts to 
accurately and effectively identify and police self-referral 
violations.

Delaying Issuance of the Final OIG Regulations

    Comment: One commenter asked that issuance of the OIG final penalty 
provisions be delayed until HCFA has promulgated both sets of final 
implementing regulations addressing prohibited referrals and prohibited 
arrangements and schemes under section 1877 of the Act.
    Response: As indicated above, HCFA plans two separate rulemaking 
initiatives--one addressing clinical laboratory services and a second 
for designated health services--to address the prohibitions set forth 
in section 1877 of the Act. The OIG has always maintained, however, 
that its statutory CMP authorities are independent authorities under 
which it may bring enforcement actions before regulations are 
published. For that reason, we do not believe that it is necessary for 
the OIG to wait upon finalization of HCFA's regulations to publish in 
final form our CMP regulations addressing the penalty and enforcement 
provisions of sections 1877 (g)(3) and (g)(4).

IV. Technical Changes

    As discussed above, we are incorporating into this final rule the 
expansion of section 1877 resulting from OBRA 1993 to include Medicare 
payments for much of the health care industry, i.e., for clinical 
laboratory services and the additional ten ``designated health 
services'' effective for referrals made after December 31, 1994.

V. Cross-References to the HCFA Regulations

    Sections 1003.100(b)(1) (ix)-(xi), 1003.102(a)(5) and 1003.102 
(b)(9) and (b)(10) cross-reference HCFA regulations' Secs. 411.351 and 
411.353 that will not be codified until the HCFA Physician Referral 
rules are published in final form. We note that these citations to the 
HCFA regulations are tentative and will be amended, if necessary, when 
those provisions are finalized.

VI. Regulatory Impact Statement

    The Office of Management and Budget has reviewed this final rule 
with comment period in accordance with the provisions of Executive 
Order 12866. As discussed above, the provisions contained in this 
rulemaking set forth new authorities to the OIG for levying CMPs 
against persons or entities that file claims for services furnished on 
the basis of prohibited referrals or who engaged in prohibited 
circumvention schemes proscribed by statute. These provisions are a 
result of statutory changes and serve to clarify departmental policy 
with respect to the imposition of CMPs against persons and entities who 
violate the statute. We believe that the great majority of providers 
and practitioners do not engage in such prohibited activities and 
practices discussed in these regulations. As a result, we believe that 
the aggregate economic impact of these provisions will be minimal, 
affecting only those who have engaged in prohibited behavior in 
violation of the statute. As such, this final rule should have no 
effect on the economy or on Federal or State expenditures.
    In addition, we generally prepare a regulatory flexibility analysis 
consistent with the Regulatory Flexibility Act (5 U.S.C. 601 through 
612) unless the Secretary certifies that a regulation will not have a 
significant economic impact on a substantial number of small business 
entities. While some sanctions and penalties may have an impact on 
small entities, we do not anticipate that a substantial number of these 
small entities will be significantly affected by this rulemaking. 
Therefore, we have concluded, and the Secretary certifies, that a 
regulatory flexibility analysis is not required for this final rule.

List of Subjects in 42 CFR Part 1003

    Administrative practice and procedure, Fraud, Grant programs--
health, Health facilities, Health professions, Maternal and child 
health, Medicaid, Medicare, Penalties.

    42 CFR part 1003 is amended as set forth below:

PART 1003--CIVIL MONEY PENALTIES, ASSESSMENTS AND EXCLUSIONS

    1. The authority citation for part 1003 is revised to read as 
follows:

    Authority: 42 U.S.C. 1302, 1320-7, 1320a-7a, 1320b-10, 1395u(j), 
1395u(k), 1395dd(d)(1), 1395mm, 1395nn(g), 1395ss(d), 1396b(m), 
11131(c) and 11137(b)(2).

    2. Section 1003.100 is amended by revising paragraph (a); by 
republishing paragraph (b)(1) introductory text; by revising paragraphs 
(b)(1)(vi) and (b)(1)(vii); and by adding new paragraphs (b)(1)(viii)-
(xi) to read as follows:


Sec. 1003.100  Basis and purpose.

    (a) Basis. This part implements sections 1128(c), 1128A, 1140, 
1842(j), 1842(k), 1876(i)(6), 1877(g), 1882(d) and 1903(m)(5) of the 
Social Security Act, and sections 421(c) and 427(b)(2) of Pub. L. 99-
660 (42 U.S.C. 1320a-7, 1320a-7a, 1320a-7(c), 1320b(10), 1395mm, 
1395ss(d), 1395u(j), 1395u(k), 1396b(m), 11131(c) and 11137(b)(2)).
    (b) Purpose. * * *
    (1) Providers for the imposition of civil money penalties and, as 
applicable, assessments against persons who--
* * * * *
[[Page 16584]]

    (vi) Violate a requirement of section 1867 of the Act or 
Sec. 489.24 of this title;
    (vii) Substantially fail to provide an enrollee with required 
medically necessary items and services, or engage in certain marketing, 
enrollment, reporting, claims payment, employment or contracting 
abuses; or
    (viii) Have submitted certain prohibited claims under the Medicare 
program;
    (ix) Present or cause to be presented a bill or claim for 
designated health service (as defined in Sec. 411.351 of this title) 
that they know, or should know, were furnished in accordance with a 
referral prohibited under Sec. 411.353 of this title;
    (x) Have collected amounts that they know or should know were 
billed in violation of Sec. 411.353 of this title and have not refunded 
the amounts collected on a timely basis; or
    (xi) Are physicians or entities that enter into an arrangement or 
scheme that they know or should know has as a principal purpose the 
assuring of referrals by the physician to a particular entity which, if 
made directly, would violate the provisions of Sec. 411.353 of this 
title.
* * * * *
    3. Section 1003.101 is amended by adding a definition for the term 
timely basis to read as follows:


Sec. 1003.101  Definitions

* * * * *
    Timely basis means, in accordance with Sec. 1003.102(b)(9) of this 
part, the 60-day period from the time the prohibited amounts are 
collected by the individual or the entity.
* * * * *
    4. Section 1003.102 is amended by revising paragraphs (a)(3), 
(a)(4) introductory test, and (a)(4)(iii); and by adding paragraphs 
(a)(5), (b)(9) and (b)(10) to read as follows:


Sec. 1003.102  Basis for civil money penalties and assessments.

    (a) * * *
    (3) An item or service furnished during a period in which the 
person was excluded from participation in the program to which the 
claim was made in accordance with a determination made under sections 
1128 (42 U.S.C. 1320a-7), 1128A (42 U.S.C. 1320a-7a), 1156 (42 U.S.C. 
1320c-5), 1160(b) as in effect on September 2, 1982 (42 U.S.C. 1320c-
9(b)), 1842(j)(2) (42 U.S.C. 1395u(j)), 1862(d) as in effect on August 
18, 1987 (42 U.S.C. 1395y(d)), or 1866(b) (42 U.S.C. 1395cc(b));
    (4) A physician's services (or an item or service) for which the 
person knew, or should have known, that the individual who furnished 
(or supervised the furnishing of) the service--
* * * * *
    (iii) Represented to the patient at the time the service was 
furnished that the physician was certified in a medical specialty board 
when he or she was not so certified; or
    (5) A payment that such person knows, or should know, may not be 
made under Sec. 411.353 of this title.
    (b) * * *
    (9) Has not refunded on a timely basis, as defined in Sec. 1003.101 
of this part, amounts collected as the result of billing an individual, 
third party payer or other entity for a designated health service that 
was provided in accordance with a prohibited referral as described in 
Sec. 411.353 of this title;
    (10) Is a physician or entity that enters into--
    (i) A cross referral arrangement, for example, whereby the 
physician owners of entity ``X'' refer to entity ``Y,'' and the 
physician owners of entity ``Y'' refer to entity ``X'' in violation of 
Sec. 411.353 of this title, or
    (ii) Any other arrangement or scheme that the physician or entity 
knows, or should know, has a principal purpose of circumventing the 
prohibitions of Sec. 411.353 of this title.
* * * * *
    5. Section 1003.103 is amended by revising paragraphs (a) and (b) 
to read as follows:


Sec. 1003.103  Amount of penalty.

    (a) Except as provided in paragraphs (b), (c) and (d) of this 
section, the OIG may impose a penalty of not more than $2,000 for each 
item or service that is subject to a determination under Sec. 1003.102.
    (b) The OIG may impose a penalty of not more than $15,000 for each 
person with respect to whom a determination was made that false or 
misleading information was given under Sec. 1003.102(b)(4), or for each 
item and service that is subject to a determination under 
Sec. 1003.102(a)(5) or Sec. 1003.102(b)(9) of this part. The OIG may 
impose a penalty of not more than $100,000 for each arrangement or 
scheme that is subject to a determination under Sec. 1003.102(b)(10) of 
this part.
* * * * *
    6. Section 1003.106 is amended by revising paragraph (a)(1) 
introductory text and paragraph (a)(1)(iv); by redesignating paragraph 
(a)(1)(v) as paragraph (a)(1)(vii); and by adding new paragraphs 
(a)(1)(v) and (a)(1)(vi) to read as follows:


Sec. 1003.106  Determination regarding the amount of the penalty and 
assessment.

    (a) Amount of penalty. (1) In determining the amount of any penalty 
or assessment in accordance with Sec. 1003.102 (a), (b)(1), (b)(4), 
(b)(9), and (b)(10), the Department will take into account--
* * * * *
    (iv) The financial condition of the person presenting the claim or 
request for payment, or giving the information;
    (v) The completeness and timeliness of the refund with respect to 
Sec. 1003.102(b)(9);
    (vi) The amount of financial interest involved with respect to 
Sec. 1003.102(b)(10); and
* * * * *
    Dated: October 4, 1994.
June Gibbs Brown,
Inspector General.

    Approved: December 30, 1994.
Donna E. Shalala,
Secretary.
[FR Doc. 95-7845 Filed 3-30-95; 8:45 am]
BILLING CODE 4150-04-M