New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
Part 515 - Provider Sanctions
Section 515.2 - Unacceptable practices under the medical assistance program
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 515.2
Current through Register Vol. 46, No. 39, September 25, 2024
(a) General. An unacceptable practice is conduct by a person which is contrary to:
(1) the official rules and regulations of the
department;
(2) the published fees,
rates, claiming instructions or procedures of the department;
(3) the official rules and regulations of the
Departments of Health, Education and Mental Hygiene, including the latter
department's offices and divisions, relating to standards for medical care and
services under the program; or
(4)
the regulations of the Federal Department of Health and Human Services
promulgated under title XIX of the Federal Social Security Act.
(b) Conduct included. An unacceptable practice is conduct which constitutes fraud or abuse and includes the practices specifically enumerated in this subdivision.
(1) False claims.
(i) Submitting, or causing to be submitted, a
claim or claims for:
(a) unfurnished medical
care, services or supplies;
(b) an
amount in excess of established rates or fees;
(c) medical care, services or supplies
provided at a frequency or in an amount not medically necessary; or
(d) amounts substantially in excess of the
customary charges or costs to the general public.
(ii) Inducing, or seeking to induce, any
person to submit a false claim under this subdivision.
(2) False statements.
(i) Making, or causing to be made any false,
fictitious or fraudulent statement or misrepresentation of material fact in
claiming a medical assistance payment, or for use in determining the right to
payment.
(ii) Inducing or seeking
to induce the making of any false, fictitious or fraudulent statement or a
misrepresentation of material fact.
(3) Failure to disclose. Having knowledge of
any event affecting the right to payment of any person and concealing or
failing to disclose the event with the intention that a payment be made when
not authorized or in a greater amount than due.
(4) Conversion. Converting a medical
assistance payment, or any part of such payment, to a use or benefit other than
for the use and benefit intended by the medical assistance program.
(5) Bribes and kickbacks. Unless the discount
or reduction in price is disclosed to the client and the department and
reflected in a claim, or a payment is made pursuant to a valid
employer-employee relationship, the following activities are unacceptable
practices:
(i) soliciting or receiving either
directly or indirectly any payment (including any kickback, bribe, referral
fee, rebate or discount), whether in cash or in kind, in return for referring a
client to a person for any medical care, services or supplies for which payment
is claimed under the program;
(ii)
soliciting or receiving either directly or indirectly any payment (including
any kickback, bribe, referral fee, rebate or discount), whether in cash or in
kind, in return for purchasing, leasing, ordering or recommending any medical
care, services or supplies for which payment is claimed under the
program;
(iii) offering or paying
either directly or indirectly any payment (including any kickback, bribe,
referral fee, rebate or discount), whether in cash or in kind, in return for
referring a client to a person for any medical care, services or supplies for
which payment is claimed under the program; or
(iv) offering or paying either directly or
indirectly any payment (including any kickback, bribe, referral fee, rebate or
discount), whether in cash or in kind, in return for purchasing, leasing,
ordering or recommending any medical care, services or supplies for which
payment is claimed under the program.
(6) Unacceptable recordkeeping. Failing to
maintain or to make available for purposes of audit or investigation records
necessary to fully disclose the medical necessity for and the nature and extent
of the medical care, services or supplies furnished, or to comply with other
requirements of this Title.
(7)
Employment of sanctioned persons. Submitting claims or accepting payment for
medical care, services or supplies furnished by a person suspended,
disqualified or otherwise terminated from participation in the program or
furnished in violation of any condition of participation in the
program.
(8) Receiving additional
payments. Seeking or accepting any gift, money, donation or other consideration
in addition to the amount paid or payable under the program for any medical
care, services or supplies for which a claim is made.
(9) Client deception. Deceiving, misleading
or threatening a client, or charging or agreeing to charge or collect any fee
in excess of the maximum fee, rate or schedule amount from a client.
(10) Conspiracy. Making any agreement,
combination or conspiracy to defraud the program by obtaining, or aiding anyone
to obtain, payment of any false, fictitious or fraudulent claim.
(11) Excessive services. Furnishing or
ordering medical care, services or supplies that are substantially in excess of
the client's needs.
(12) Failure to
meet recognized standards. Furnishing medical care, services or supplies that
fail to meet professionally recognized standards for health care or which are
beyond the scope of the person's professional qualifications or
licensure.
(13) Unlawful
discrimination. Illegally discriminating in the furnishing of medical care,
services or supplies based upon the client's race, color, national origin,
religion, sex, age or handicapping condition.
(14) Factoring. Assigning payments under the
program to a factor, either directly or by power of attorney; or receiving
payment through any person whose compensation is not related to the cost of
processing the claim, is related to the amount collected or is dependent upon
collection of the payment.
(15)
Solicitation of clients. Offering or providing any premium or inducement to a
client in return for the client's patronage of the provider or other person to
receive care, services or supplies under the program.
(16) Verification of MA eligibility:
(i) failing to use the Medicaid Eligibility
Terminal (MET) verification procedure, as required by Part 514 of this Title,
in a significant number of cases and such failure is unjustified;
(ii) failing to use the card swipe capability
of the MET, as required by Part 514 of this Title, in a significant number of
cases and such failure is unjustified;
(iii) failing to post orders for medical
care, services or supplies in the electronic Medicaid eligibility verification
system (EMEVS), as required by Part 514 of this Title, in a significant number
of cases and such failure is unjustified; or
(iv) failing to clear prescription or fiscal
orders which are required to be posted to EMEVS, as required by Part 514 of
this Title, in a significant number of cases and such failure is
unjustified.
(17) Denial
of services. Denying services to a recipient based in whole or in part upon the
recipient's inability to pay a co-payment for medical care, services or
supplies.
(18) Other prohibited
acts. With respect to any person not a provider, committing any act which would
result in the termination of a provider's enrollment in the program pursuant to
section
504.7
of this Title.
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