A determination or decision may be reopened at any time if it was procured by fraud
or similar fault, regardless of whether criminal prosecution has been or will be instituted.
The fraud or similar fault may be that of the beneficiary, provider, physician, or
any other person.
“Similar fault” means (A) an act which approximates fraud; i.e., the furnishing of information which
the individual knew was incorrect or incomplete, or the deliberate concealment of
information, without a judicial finding of fraud, or (B) an established pattern of
billing for excessive or noncovered services, including services not medically reasonable
and necessary or custodial care.