OAR 410-120-1400: Provider Sanctions

(1) The Authority recognizes two classes of Medicaid provider sanctions, mandatory and discretionary, outlined in sections (4) and (5) of this rule. (2) The Authority shall impose sanctions on Medicaid providers at the discretion of the Authority Director or delegate. Nothing in this rule limits the ability of Authority or the Oregon Department of Human Services (ODHS) to also seek monetary recovery, or pursue remedies specific to a contract with Authority or ODHS, or as otherwise permitted by state or federal law. Authority sanctions of its contracted managed care entities are governed by OAR 410-141-3530. (3) Authority may sanction and suspend or terminate a provider who: (a) is applying for enrollment, re-enrollment or revalidation as an Oregon Medicaid provider; (b) is enrolled as an Oregon Medicaid provider; regardless of whether enrollment is continuous or active; or (c) was an enrolled Oregon Medicaid provider at the time the sanctionable conduct, action, conditions or activity occurred. (4) The Authority shall impose mandatory sanctions and deny enrollment, suspend or terminate the enrollment of the provider from participation in Oregon’s medical assistance programs, regardless of whether the provider was directly enrolled or contracted by Authority or was enrolled or contracted by an Authority designee including but not limited to ODHS: (a) When a provider, or any person with five (5) percent or more direct or indirect ownership interest in the provider, or any agent, affiliate or managing employee of the provider is, or was in the preceding then (10) years, convicted (as that term is defined in 42 CFR 1001.2) of a felony or misdemeanor related to a crime, or violation of Title XVIII, XIX, or XX of the Social Security Act, any other federal program, or related state laws; regardless of whether an appeal from that judgment is pending; (b) When a provider, or any person with five (5) percent or more direct or indirect ownership interest in the provider, or any agent, affiliate or managing employee of the provider, is excluded from participation in federal or state health care programs by the Office of the Inspector General of the U.S. Department of Health and Human Services (OIG) or from Medicare (Title XVIII) program of the Social Security Act as determined by the Secretary of Health and Human Services; regardless of whether an appeal from that judgment is pending. The provider shall also be terminated or suspended from participation with the Authority for the duration of exclusion or suspension from the Medicare program or by the OIG; (c) When a provider fails to disclose ownership or controlling information required under 42 CFR 455.104 that is required to be reported at the time the provider submits a provider enrollment application, or when there is a material change in the information that must be reported or information related to business transactions required to be provided under 42 CFR 455.105 upon request of federal or state authorities. (d) When a provider, or any person with a five (5) percent or greater direct or indirect ownership or controlling interest in the provider, fails to submit sets of fingerprints in a form and manner determined by the Authority within 30 days of CMS or an Authority request; (e) When a provider, or any person with a five (5) percent or greater direct or indirect ownership or control interest, an agent, affiliate or managing employee of the provider, fails to submit timely and accurate information, comply with Authority screening methods, or both as required under 42 CFR 455 Subpart E; (f) When a provider fails to permit access to a provider location for any site visit under 42 CFR §455.432; unless the Authority determines the termination is not in the best interest of the Medicaid program. 42 CFR 455.416(f); (g) When a provider is suspended or excluded from participation in a state Medicaid or CHIP program for reasons related to professional competence, professional performance, debarment or other reason; (h) If the Authority: (A) Determines that the provider has falsified any information provided on the application for enrollment; or (B) Cannot verify the identity of the provider. (i) When a provider is convicted of fraud related to any federal, state, or locally financed health care program or commits fraud, receives kickbacks, or commits other acts that are subject to criminal or civil penalties under the Medicare or Medicaid statutes; (j) When a provider is convicted of interfering with the investigation of health care fraud; (k) When a provider is convicted of unlawfully manufacturing, distributing, prescribing, or dispensing a controlled substance; (l) When a provider, or any person with five (5) percent or more direct or indirect ownership interest in the provider, or any agent, affiliate or managing employee of the provider, is subject to an adverse Legal Action including conviction of a felony crime against persons, financial crime(s) or misdemeanor conviction of patient abuse or neglect, theft, embezzlement or fraud; (m) When there is a credible allegation of fraud as defined in 42 CFR 455.2 for which an investigation is pending under the Medicaid program, unless good cause not to suspend payments exists, in accordance with 42 CFR §455.23; (n) When Authority receives a referral from a Medicaid Fraud Control Unit (MFCU), Authority will initiate any available administrative or judicial action to recover improper payments to a provider and suspend the provider to prevent future payments, unless good cause not to suspend payments exists, in accordance with 42 CFR §455.23; (o) When the provider’s enrollment has been terminated or revoked for cause by Medicare or another state’s Medicaid program and such termination has been published in the Data Exchange System (DEX), the Authority will terminate the provider’s enrollment in its program pursuant to 42 CFR 455.416(c) and455.101. (5) The Authority may impose discretionary sanctions and deny enrollment, suspend or terminate a provider when the Authority determines that the provider fails to meet one or more of the Authority’s requirements in all applicable administrative rules or the contract between Authority and the provider governing participation in its medical assistance programs. Conditions that may result in a discretionary sanction include but are not limited to: (a) breech of the provider agreement; (b) actions of any state licensing authority for reasons relating to the provider's professional competence, professional conduct, quality of care, or financial integrity including but not limited to: (A) Having the health care license suspended or revoked, or otherwise loses their license; or (B) Surrendering their license while a formal disciplinary proceeding is pending before the licensing authority. (c) Suspended or excluded from participation in any federal or state health care program for reasons related to professional competence, professional performance, or other reason; (d) Billing excessive charges (i.e., charges more than the usual charge). Furnishes items or services substantially more than the Authority client’s needs or more than those services ordered by a medical provider or more than generally accepted standards or of a quality that fails to meet professionally recognized standards; (e) Fails to furnish medically necessary services as required by law or contract with the Authority if the failure has adversely affected (or has a substantial likelihood of adversely affecting) the Authority client; (f) Fails to disclose required ownership information; (g) Fails to supply requested records and information on subcontractors, providers, and suppliers of goods or services; (h) Fails to supply requested payment information; (i) Fails to provide or disclose requested information or documentation to Authority, within the timeframe listed on the Authority’s written request; (j) Fails to grant access or to furnish as requested, records, or grant access to facilities upon request of the Authority or designee, ODHS, the Authority’s Office of Program Integrity (OPI), OIG, or the State of Oregon's Department of Justice (DOJ) Medicaid Fraud Control Unit (MFCU) conducting their regulatory or statutory functions; (k) In the case of a hospital, fails to take corrective action as required by the Authority, based on information supplied by the Quality Improvement Organization to prevent or correct inappropriate admissions or practice patterns, within the time specified by the Authority; (L) Defaults on repayment of federal or state government scholarship obligations or loans in connection with the provider's health profession education. The Authority: (A) Shall make a reasonable effort to secure payment; (B) Shall take into account access of beneficiaries to services; and (C) May not exclude a community's sole physician or source of essential specialized services. (m) Submits one or more claims with required data missing or incorrect; (n) Fails to comply with the requirements of OAR 410-120-1280, Ch 410, Ch 943, Ch 309 or any other OAR CH applicable to the service or good when billing or submitting claims or encounters to Authority. (o) Fails to develop, maintain, and retain in accordance with OAR 410-120-1360 and relevant rules Ch 410, Ch 943, Ch 309 or any other OAR CH applicable to the service or good and standards adequate clinical or other records that document the medical appropriateness, nature, and extent of the health care provided; (p) Fails to develop, maintain, and retain in accordance with OAR 410-120-1360 and relevant rules in Ch 410, Ch 943, Ch 309 or any other OAR CH applicable to the provider and adequate financial records as defined in OAR 410-120-0000 that document charges incurred by a client and payments received from any source; (q) Fails to develop, maintain, and retain adequate financial or other records of all assets, liabilities, income, and expenses that support information submitted on a cost report; (r) Fails to follow generally accepted accounting principles or accounting standards or cost principles sanctioned by recognized authoritative bodies such as the Governmental Accounting Standard Board and the Financial Accounting Standards Board and required by federal or state laws, rules, or regulations applicable to Medicaid; (s) Submits claims or written orders contrary to generally accepted standards of medical practice of the provider receiving or requesting payment; (t) Submits claims or encounters for services that exceed that requested or agreed to by the member or the responsible relative or guardian or requested by another medical provider; (u) Breaches the terms of the provider contract or the provider enrollment agreement with the Authority or Oregon Department of Human Services (ODHS). This includes failure to comply with the terms of the provider certifications on the medical claim form; (v) Rebates or accepts a fee or portion of a fee or charge for an Authority client referral, or collects a portion of a service fee from the client and bills the Authority for the same service; (w) Fails to disclose information requested on the provider enrollment application or as otherwise requested by Authority; (x) Fails to correct deficiencies in operations after receiving written notice of the deficiencies from the Authority; including deficiencies in licensing or certification procedures; (y) Submits any claim or encounter for payment for which payment has already been made by the Authority or any other source unless the amount of the payment from the other source is clearly identified; (z) Threatens, intimidates, or harasses members or their relatives in an attempt to influence payment rates or affect the outcome of disputes between the provider and the Authority; (aa) Fails to properly account for an Authority member's Personal Incidental Funds, including but not limited to using a client's Personal Incidental Funds for payment of services that are included in a medical facility's all-inclusive rates; (bb) Provides or bills for services provided by ineligible or unsupervised or unqualified employees, providers, or interns; (cc) Participates in collusion that results in an inappropriate money flow between the parties involved, for example, referring clients unnecessarily to another provider; (dd) Refuses or fails to repay in accordance with an accepted schedule an overpayment established by the Authority, Authority’s OPI, MFCU or as ordered by a court; (ee) Refuses or fails to repay in accordance with an accepted schedule repayment of identified overpayment or settlement agreements established by Authority, Authority OPI, MFCU or as ordered by a court; (ff) Fails to report to Authority or ODHS payments received from any other source after the Authority made payment for the service; (gg) Fails to comply with federal or state statutes and regulations or policies of the Authority or ODHS that are applicable to the provider; (hh) Fails to obtain or maintain required provider credentials or has credentials suspended or otherwise revoked by the credentialing entity, for any reason; (ii) Fails to correct subcontractor deficiencies in operations or non-compliance with Medicaid program requirements after receiving written notice of the deficiencies from the Authority; (jj) Acts to discriminate among members on the basis of their health status or need for health care services, or on the basis of race, color, national origin, religion, sex, sexual orientation, marital status, age, or disability; violates member civil rights under Title VI of the Civil Rights Act and ORS Chapter 659A; (kk) When a person with five (5) percent or more direct or indirect ownership interest in the provider, or an agent, affiliate, supplier or managing employee of the provider is found to be in violation, independently or in tandem with the provider, of one or more of the provision of section (4) or (5) of this rule; (LL) When a MCE participating provider or subcontractor enrolled or seeking enrollment as an encounter only provider is found to be in violation of one or more of the provision of section (4) or (5) of this rule; (mm) Submits a bill or invoice or otherwise seeks payment from a member for any services covered by Medicaid fee-for-service or through contracted health care plans, except as authorized by OAR 410-120-1280. If the member was eligible for medical assistance on the date of service, and the provider does not have a completed signed agreement to pay form (3165, 3166), the provider is not allowed to bill the member, collect payment from the member, or assign an unpaid claim to a collection agency or similar entity pursuant to ORS 414.066, except as authorized by section (5) of OAR 410-120-1280. The Authority sanction of the provider may include but is not limited to any amount necessary to fully repay the member for the billed services, fines, fees or other financial penalties imposed on the member by the provider or any third party collections agency, and any accrued interest. (nn) Failure to comply with Authority or its designee’s notice that the provider is in violation of ORS 414.066 within 30 days or within the time required in the Authority’s written notice; (oo) Failure to comply with federal or state statutes and regulations or policies of the Authority that are applicable to the provider; (pp) No claims have been submitted in an 18-month period. The provider must reapply for enrollment; (6) A provider excluded, suspended, or terminated from participation in a federal or state medical program, such as Medicare or Medicaid or CHIP, or whose license or certification to practice is suspended or revoked by a state licensing board or Authority may not submit encounters or claims to the Authority for payment, either personally or through claims submitted by any billing agent/service, billing provider, or other provider for any services or supplies provided under the medical assistance programs, except those services or supplies provided prior to the date of exclusion, suspension, or termination; unless good cause not to suspend payments exists, in accordance with 42 CFR §455.23. (7) A Provider may not submit encounters or claims for payment to the Authority for payment for any services or supplies provided by an individual provider or provider entity that is excluded, suspended, or terminated from participation in a federal or state medical program or whose license to practice is suspended or revoked by a state licensing board, except for those services or supplies provided prior to the date of exclusion, suspension, or termination; unless good cause not to suspend payments exists, in accordance with 42 CFR §455.23. (8) When any one of the provisions of sections (4) or (5) of this rule are violated, the Authority may suspend or terminate the billing provider’s enrollment agreement or the enrollment agreement of any individual provider who is in violation. When a provider is sanctioned, all other enrolled providers in which the sanctioned provider has ownership or controlling interest of five (5) percent or greater, may also be sanctioned and suspended or terminated. (9) When any of the provisions of section (4) are violated, Authority shall withhold and recover all payments made to the provider for services furnished after the effective date of the sanction; unless good cause not to recover payments exists, in accordance with 42 CFR §455.23. When provisions of section (5) are violated, Authority may withhold and recover all payments made to the provider for services furnished after the effective date of the sanction. (10) When a provider sanctioned as a result of exclusion from participation in federal or another state’s health care programs the scope of the provider appeal of the Authority’s Action is limited to a review of whether the provider was, in fact, terminated by the initiating program. The appeal will not review the underlying reasons for the initiating termination. The provider must contact the federal or state agency which issued the initial decision. (11) Authority shall, for any provider or any person with a relationship with the provider who meets the circumstances for exclusion listed in 42 CFR 1001.1001, promptly notify the OIG of any action(s) Authority takes on the provider’s application for enrollment in the program and any action(s) taken to limit the ability of a provider, whether an individual or entity, to participate in Oregon’s Medicaid program, regardless of what such an action is called. This includes, but is not limited to, suspension actions, settlement agreements and situations where the provider voluntarily withdraws from the program to avoid formal sanction(s). (12) Authority shall, for any provider sanctioned by the Authority under this rule 410-120-1400 list the name(s) of the provider, NPI, duration and the effective date of the sanction on the Authority’s website.