Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.10-007 - Section I Provider Manual Update Transmittal
Universal Citation: AR Admin Rules 016.06.10-007
Current through Register Vol. 49, No. 9, September, 2024
142.500 Conditions Related to Fraud and Abuse
A. Any provider who engages in fraudulent
billing practices will be immediately suspended from participation until these
practices are evaluated and resolved. Also, any provider discovered to be
involved in fraudulent billing practices or found to be accepting or soliciting
unearned rebates, refunds or other unearned considerations, whether in the form
of money or otherwise, will be referred to the appropriate legal agency for
prosecution under applicable federal or state laws.
B. Any provider who engages in abuse or
over-utilization of services provided to Medicaid beneficiaries, when such
abuse or over-utilization has been determined by DMS professional staff,
medical consultants, contractors or designees, may be terminated from
participation in the Medicaid Program, required to repay monies paid by the
Medicaid Program for such services or have other appropriate action taken upon
recommendation of the above-referenced parties.
C. Except where participation has been
terminated, each provider who has been sanctioned may be required to
participate ina provider education program as a condition of continued
participation. Provider education programs will include, at a minimum, the
following:
1. Instruction on admissions and
authorization for payments
2.
Instruction on the use and format of required program forms
3. Instruction on key provisions of the
Medicaid Program
4. Instruction on
reimbursement rates
5. Instruction
on how to inquire about program requirements, payment or billing problems and
the overall operation of the program
D. Providers are obligated to screen all
employees and contractorsto determine; if any of them are excluded from
participation in Federal health care programs.
1. Providers can search the LEIE website
maintained by the United States Health and Human Services Office of Inspector
General which contains the names of any excluded individual or, entity.
(
2. Providers can find a Department of Human
Services excluded list on the Arkansas Department of Human Services website at:
https://ardhs.sharepointsite.net/ExcludedProvidersList/Excluded%20Provided%20List.html .
This list contains the names of any excluded individuals or entities. The
Arkansas Department of Finance and Administration, Office of State Procurement,
maintains a list of suspended or debarredivendprstat:
http://www.dfa.arkansas.aov/offices/procurement/auidelines/Paqes/suspendedDebarredVendors.aspx
3. If providers discover any exclusion
information other that what is provided on the websites, providers should
report that information to Provider Enrollment.
4. Providers should check the websites
monthly to capture exclusions and reinstatements which may have occurred since
the last search.
E. No
Medicaid payments can be made for any times or services directed or prescribed
by an excluded provider; or any other authorized person, when the individual
entity furnishing the services knew or should have known of the exclusion. This
prohibition applies even when the Medicaid payment itself is made to another
provider, practitioner or supplier that is not excluded. (See
42 CFR section
1001.1901(b)).The following
listing sets forth examples of types of services that are reimbursed by
Medicaid which, when provided by excluded parties, are not reimbursable:
1. Nurses, technicians or other excluded
individuals who work for a hospital, nursing home, home health agency or
physician practice, where such services are related to administrative duties,
preparation of surgical trays or review of treatment plans if such services are
reimbursed directly or indirectly by a Medicaid program, even if the
individuals do not furnish direct medical care to Medicaid
beneficiaries.
2. Services
performed by excluded pharmacists or other excluded individuals who input
prescription information for pharmacy billing or who-are involved in any way
infilling prescriptions for drugs reimbursed directly or indirectly by a
Medicaid program.
3. Services
performed by excluded ambulance drivers, dispatchers or other employee's
patients or nursing home residents.
4. Services performed for program
beneficiaries by excluded individuals who sell, deliver or refill orders for
medical'devices or equipment being reimbursed by a Medicaid program.
5. Services performed by excluded social
workers who are employed by health care entities to provide services to
Medicaid beneficiaries and whose services are reimbursed, directly or
indirectly by a Medicaid program.
6., Services performed by an excluded
administrator, billing agent, accountant,
claims processor or utilization reviewer that are related to and reimbursed, directly or indirectly by a Medicaid program.
7. Items or services provided to a Medicaid
beneficiary by an excluded individual who works for an entity that has a
contractual agreement with, and is paid by, a Medicaid program.
8. Items or equipment "sold by an excluded
manufacturer or supplier, used in the care or treatment of beneficiaries and
reimbursed, directly or indirectly by a Medicaid program.
F. Civil monetary penalties may be imposed
against Medicaid providers who employ or enter into contracts with excluded
individuals or entities to provider items or services to Medicaid
beneficiaries. (See 1128A (a) (6) of the Act and 42 CFR section 1003.102(a) (2)
.)
Disclaimer: These regulations may not be the most recent version. Arkansas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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