Mont. Admin. R. 37.85.501 - GROUNDS FOR SANCTIONING
(1) Sanctions may
be imposed by the department against a provider of medical assistance, provided
under ARM Title 37, chapters 40, 80, 82, 83, 85, 86, 88, for any one or more of
the following reasons:
(a) Presenting or
causing to be presented for payment any false or fraudulent claim for services
or merchandise.
(b) Submitting or
causing to be submitted false information for the purpose of obtaining greater
compensation than that to which the provider is legally entitled under the
rules of the department.
(c)
Submitting or causing to be submitted false information for the purpose of
meeting prior authorization requirements.
(d) Failure to maintain and retain records
required by the rules of the department.
(e) Failure to disclose or make available
required records to the department, its authorized agent or other legally
authorized persons, organizations, or governmental entities.
(f) Failure to provide and maintain services
to Medicaid recipients at a quality that is within accepted medical community
standards as adjudged by a body of peers.
(g) Engaging in a course of conduct or
performing an act which the department's rules or the decision of the
applicable professional peer review committee, or licensing board, have
determined to be improper or abusive of the Montana Medicaid program; or
continuing such conduct following notification that the conduct should
cease.
(h) Breach of the terms of
the provider contract or failure to comply with the terms of the provider
certification on medical assistance claim forms or the failure to comply with
requirements imposed by the rules of the department.
(i) Over-utilizing the Montana Medicaid
program by inducing, or otherwise causing a recipient to receive services or
goods not medically necessary.
(j)
Rebating or accepting a fee or portion of a fee or charge for a Medicaid
patient referral.
(k) Violating any
provision of the state Medicaid law, Title 53, chapter 6, MCA or any rule
promulgated pursuant thereto, or violating any provision of Title XIX of the
Social Security Act or any regulation promulgated pursuant thereto.
(l) Submission of a false or fraudulent
application for provider status.
(m) Violations of any statutes, regulations
or code of ethics governing the conduct of occupations or professions or
regulated industries.
(n)
Conviction of a criminal offense relating to medical assistance programs
administered by the department or provided under contract with the state; or
conviction for negligent practice resulting in death or injury to
patients.
(o) Failure to meet
requirements of state or federal law for participation (e.g.
licensure).
(p) Exclusion from the
Medicare program (Title XVIII of the Social Security Act) because of fraudulent
or abusive practices.
(q) Charging
Medicaid recipients for amounts over and above the amounts paid by the
department for services rendered, except as specifically allowed under ARM
37.83.825 and
37.83.826.
(r) Refusal to execute a new provider
agreement when requested to do so.
(s) Failure to correct deficiencies as
defined by the ARM or federal regulation after receiving written notice of
these deficiencies from the department, or the federal Department of Health and
Human Services. The standards set forth at 42 CFR Part 442, Part 483 and Part
488, updated through February 2004, which identify deficiencies for providers
of intermediate care facilities for the mentally retarded, skilled nursing and
nursing facility services, are incorporated by reference. A copy of 42 CFR Part
442, Part 483 and Part 488, updated through February 2004, are available from
the Department of Public Health and Human Services, Quality Assurance Division,
2401 Colonial Drive, P.O. Box 202653, Helena, MT 59620-2953.
(t) Formal reprimand or censure by an
association of the provider's peers for unethical practices.
(u) Suspension or termination from
participation in another government medical program including but not limited
to workers' compensation, crippled children's services, rehabilitation services
and Medicare.
(v) Filing of
criminal indictment, information or complaint for fraudulent billing practices
or negligent practice resulting in death or injury to the provider's
patients.
(w) Civil judgement for
fraudulent billing practices or negligent practice resulting in death or injury
to the provider's patients.
(x)
Failure to repay or make acceptable arrangements for the repayment of
identified overpayments or otherwise erroneous payments.
(y) Threatening, intimidating or harassing
patients or their relatives in an attempt to influence reimbursement rates or
affect the outcome of disputes between the provider and the
department.
(z) Submitting claims
for reimbursement of costs or services which the provider knows or has reason
to know are not reimbursable.
Notes
53-2-201, 53-2-803, 53-4-111, 53-6-111, 53-6-113, MCA; IMP, 53-2-306, 53-2-801, 53-2-803, 53-4-112, 53-6-111, 53-6-131, MCA;
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