Current through all regulations passed and filed through September 16, 2024
(A) The
administrator may refuse to certify
or recertify, or may decertify from participation in the HPP, any
MCO that:
(1) Is owned, directly or indirectly, by an
individual or entity that has a felony conviction in any jurisdiction, a
conviction under a federal controlled substance act, a misdemeanor conviction
for an act involving dishonesty, fraud, or misrepresentation, a conviction for
a misdemeanor committed in the course of practice, or a felony or misdemeanor conviction involving
dishonesty, fraud, or misrepresentation related to any compensation or benefits
payable under Chapter 4121., 4123., 4127., or 4131. of the Revised Code.
(2)
Has one or more owners, shareholders, members, partners, managing employees,
officers or directors, who have a conviction as
described in paragraph (A)(1) of this rule; and including any
MCO that is no longer
so described because of a transfer of ownership or interest to an immediate
family member or a member of the person's household in anticipation of or
following a conviction as described in
paragraph (A)(1) of this rule.
(3)
Is owned directly, or indirectly, by an individual or entity who has engaged in
specific conduct which demonstrates financial irresponsibility. Such conduct
shall include, but not be limited to:
(a)
Specific examples of insolvency of businesses owned or controlled by the
individual or entity;
(b) Specific
examples of failures to pay debts or judgments;
(c) Specific examples of activity which has
defrauded any person, entity or organization, regardless of whether such
activity has resulted in criminal prosecution;
(d) Any finding of fraud in a civil or
administrative proceeding related to any compensation or benefits payable under
Chapter 4121., 4123., 4127., or 4131. of the Revised Code or the equivalent
laws of another state.
(B)
The administrator
may refuse to enroll, certify or recertify, or may terminate enrollment or
decertify from participation in the HPP, any provider or entity that:
(1)
Is owned,
directly or indirectly, by an individual or entity that has been convicted of
or pleaded guilty to a criminal offense as set forth in the appendix to rule
4123-6-02.2 of the
Administrative Code. The provider or entity is ineligible for enrollment,
certification, or recertification for the same period of ineligibility provided
in the appendix to rule
4123-6-02.2 of the
Administrative Code for the criminal offense.
(2)
Has one or more
owners, shareholders, members, partners, managing employees, officers or
directors who have a conviction or plea of guilty to a criminal offense as set
forth in the appendix to rule
4123-6-02.2 of the
Administrative Code. The provider or entity is ineligible for enrollment,
certification, or recertification for the same period of ineligibility provided
in the appendix to rule
4123-6-02.2 of the
Administrative Code for the criminal offense.
(3)
It is owned
directly, or indirectly, by an individual or entity who has engaged in specific
conduct which demonstrates financial irresponsibility as described in paragraph
(A)(3) of this rule.
(C) For the purposes
of paragraphs (A) and (B) of this rule:
(1) "Entity" means any
sole proprietorship, partnership, corporation, professional association,
limited liability company or any other business organization doing business in
this or any other state.
(2) "Immediate family
member" means a person's spouse; natural or adoptive parent; child or sibling,
stepparent, stepchild, stepbrother or stepsister; father-, mother-, daughter-,
son-, brother- or sister-in-law; grandparent or grandchild; or spouse of a
grandparent or grandchild.
(3) "Managing
employee" means an individual (including a general manager, office manager,
business manager, administrator or director) who exercises operational or
managerial control over the provider, entity or MCO or part thereof, or
directly or indirectly conducts the day-to-day operations of the provider,
entity or MCO or part thereof, or is involved in the billing functions of the
provider, entity or MCO or part thereof.
(4) "Member of household" means, with respect to a
person, any individual with whom they are sharing a common abode.
(5)
"Owned directly or indirectly" means having an interest that includes
ownership, as an individual or through any other entity or entities, of five
percent or more in the provider, entity or MCO at issue.
(D)
Notwithstanding and in addition to the provisions set forth in this rule,
pursuant to division (C)(1) of section
4121.444 of the Revised Code the
administrator may terminate any agreement between the bureau and a person or a
health care provider or managed care organization or its owner and cease
reimbursement to, decertify and terminate the enrollment of that person,
provider, organization, or owner for services rendered if any of the following
apply:
(1) The person, health care provider,
managed care organization, or its owner, or an officer, authorized agent,
associate, manager, or employee of a person, provider, or organization is
convicted of or pleads guilty to a violation of sections
2913.48 or
2923.31 to
2923.36 of the Revised Code or
any other criminal offense related to the delivery of or billing for health
care benefits.
(2) There exists an
entry of judgment against the person, health care provider, managed care
organization, or its owner, or an officer, authorized agent, associate,
manager, or employee of a person, provider, or organization and proof of the
specific intent of the person, health care provider, managed care organization,
or owner to defraud, in a civil action brought pursuant to section
4121.444 of the Revised
Code.
(3) There exists an entry of
judgment against the person, health care provider, managed care organization,
or its owner, or an officer, authorized agent, associate, manager, or employee
of a person, provider, or organization in a civil action brought pursuant to
sections 2923.31 to
2923.36 of the Revised
Code.
(E) No person, health care provider, or managed care
organization that has had its agreement with and reimbursement from the bureau
terminated by the administrator pursuant to division (C)(1) of section
4121.444 of the Revised Code, or
an owner, officer, authorized agent, associate, manager, or employee of that
person, health care provider, or managed care organization shall do either of
the following:
(1) Directly provide services
to any other bureau provider or have an ownership interest, as an individual or
through any other entity or entities, of five percent or more in a provider of
services that furnishes services to any other bureau provider;
(2) Arrange for, render, or order services
for claimants during the period that the agreement of the person, health care
provider, managed care organization, or its owner is terminated as described in
division (C)(1) of section
4121.444 of the Revised
Code;
(F) The administrator shall not terminate the
agreement or reimbursement if the person, health care provider, managed care
organization, or owner demonstrates that the person, provider, organization, or
owner did not directly or indirectly sanction the action of the authorized
agent, associate, manager, or employee that resulted in the conviction, plea of
guilty, or entry of judgment as described in division (C)(1) of section
4121.444 of the Revised
Code.
(G) Nothing in division (C) of section
4121.444 of the Revised Code
prohibits an owner, officer, authorized agent, associate, manager, or employee
of a person, health care provider, or managed care organization from entering
into an agreement with the bureau if the provider, organization, owner,
officer, authorized agent, associate, manager, or employee demonstrates absence
of knowledge of the action of the person, health care provider, or managed care
organization with which that individual or organization was formerly associated
that resulted in a conviction, plea of guilty, or entry of judgment as
described in division (C)(1) of section
4121.444 of the Revised
Code.
(H) Actions taken by the administrator pursuant to
this rule shall be subject to rule
4123-6-17 of the Administrative
Code.
