Current through March 20, 2024
Authority: IC
12-15-1-10; IC
12-15-1-15; IC
12-15-21-2
Affected: IC
4-21.5-3-6; IC
4-21.5-3-7; IC
4-21.5-4; IC 12-15
Sec. 4.
(a) If, after
investigation by the office, the IMFCU, or other governmental authority, the
office determines that a provider has violated any provision of IC 12-15, or
has violated any rule established under one (1) of those sections, the office
may impose one (1) or more of the following sanctions:
(1) Deny payment to the provider for Medicaid
services rendered during a specified period of time as provided under section 8
of this rule.
(2) Reject a
prospective provider's application for participation in Medicaid.
(3) Remove a provider's certification for
participation in Medicaid (decertify the provider).
(4) Assess a fine against the provider in an
amount not to exceed three (3) times the amounts paid to the provider in excess
of the amounts that were legally due.
(5) Require the provider to create a
corrective action plan. A corrective action plan must include the following:
(A) A timeline for coming into compliance
with state or federal requirements.
(B) The names, including title, address, and
phone number, of persons responsible for ensuring compliance with state or
federal requirements.
(C) A
description of the actions the entity will take to come into compliance with
state or federal requirements.
(D)
Any other information required by the office.
If, after sixty (60) calendar days following written notice
of a request for a corrective action plan by the state, a provider has not
submitted a corrective action plan, the provider may be subject to payment
withholding or any other sanction under this rule.
(6) Suspend a provider's Medicaid payments in
whole or in part.
(7) Terminate the
provider agreement.
(b)
Specifically, the office may impose the sanctions in subsection (a) if, after
investigation by the office, the IMFCU, or other governmental authority, the
office determines that the provider:
(1)
presented or knowingly submitted:
(A) claims
for Medicaid services:
(i) that cannot be
documented by the provider; or
(ii)
provided to a person other than a person in whose name the claim is
made;
(B) any false or
fraudulent claims for Medicaid services or merchandise;
(C) information with the intent of obtaining
greater compensation than that which the provider is legally entitled,
including charges in excess of the:
(i) fee
schedule; or
(ii) usual and
customary charges; or
(D) false information for the purpose of
meeting prior authorization requirements;
(2) engaged in a course of conduct or
performed an act deemed by the office to be abusive of the Medicaid program or
continuing the conduct following notification that the conduct should
cease;
(3) knowingly breached the
terms of the Medicaid provider certification agreement;
(4) failed to comply with the terms of the
provider certification on the Medicaid claim form;
(5) knowingly overutilized the Indiana
Medicaid program or otherwise caused the member to receive services or
merchandise not otherwise required or requested by the member;
(6) knowingly submitted:
(A) a false or fraudulent provider
agreement;
(B) claims for Medicaid
services for which federal financial participation is not available;
or
(C) any claims for Medicaid
services or merchandise arising out of any act or practice prohibited by the:
(i) criminal provisions of the Indiana Code;
or
(ii) rules of the
office;
(7)
failed to:
(A) disclose or make available to
the office, the IMFCU, or other governmental authority, after reasonable
request and notice to do so, documentation of services provided to Medicaid
members and Medicaid records of payments made therefor;
(B) comply with the requirements of
1902(a)(68) of the Social Security Act, except that such failure shall first be
sanctioned with a corrective action plan before any other sanction in
subsection (a) shall be applied; or
(C) meet standards required by the state of
Indiana or federal law for participation;
(8) knowingly charged a Medicaid member for
covered services over and above that paid for by the office;
(9) refused to execute a new provider
agreement when requested to do so;
(10) failed to:
(A) correct deficiencies to provider
operations after receiving written notice of these deficiencies from the
office; or
(B) repay or make
arrangements for the repayment of identified overpayments or otherwise
erroneous payments in accordance with state or federal law; or
(11) knowingly billed Medicaid
more than the usual and customary charge to the provider's private pay
customers.
(c) The
office may impose a sanction under IC
4-21.5-3-6. Any order issued under
this subsection shall:
(1) be served upon the
provider by certified mail, return receipt requested;
(2) contain a brief description of the
order;
(3) become final fifteen
(15) days after its receipt; and
(4) contain a statement that any appeal from
the decision of the office made under this section shall be taken in accordance
with IC 4-21.5-3-7 and section 12 of this
rule.
(d) If an
emergency exists, as determined by the office, the office may issue an
emergency order imposing a sanction identified in this section under IC
4-21.5-4. Any order issued under
this subsection shall:
(1) be served upon the
provider by certified mail, return receipt requested;
(2) become effective upon receipt;
(3) include a brief statement of the facts
and law that justifies the office's decision to issue an emergency order;
and
(4) contain a statement that
any appeal from the decision of the office made under this section shall be
taken in accordance with IC
4-21.5-3-7 and section 12 of this
rule.
(e) The decision
to impose a sanction shall be made at the discretion of the office.
(f) Prepayment review of provider claims is
not a sanction and is not subject to appeal.
