Current through Register Vol. 54, No. 44, November 2, 2024
(a) An
enrolled provider may not, either directly or indirectly, do any of the
following acts:
(1) Knowingly or
intentionally present for allowance or payment a false or fraudulent claim or
cost report for furnishing services or merchandise under MA, knowingly present
for allowance or payment a claim or cost report for medically unnecessary
services or merchandise under MA, or knowingly submit false information, for
the purpose of obtaining greater compensation than that to which the provider
is legally entitled for furnishing services or merchandise under MA.
(2) Knowingly submit false information to
obtain authorization to furnish services or items under MA.
(3) Solicit, receive, offer or pay a
remuneration, including a kickback, bribe or rebate, directly or indirectly, in
cash or in kind, from or to a person in connection with furnishing of services
or items or referral of a recipient for services and items.
(4) Submit a duplicate claim for services or
items for which the provider has already received or claimed reimbursement from
a source.
(5) Submit a claim for
services or items which were not rendered by the provider or were not rendered
to a recipient.
(6) Submit a claim
for services or items which includes costs or charges which are not related to
the cost of the services or items.
(7) Submit a claim or refer a recipient to
another provider by referral, order or prescription, for services, supplies or
equipment which are not documented in the record in the prescribed manner and
are of little or no benefit to the recipient, are below the accepted medical
treatment standards, or are not medically necessary.
(8) Submit a claim which misrepresents the
description of the services, supplies or equipment dispensed or provided, the
date of service, the identity of the recipient or of the attending,
prescribing, referring or actual provider.
(9) Submit a claim for a service or item at a
fee that is greater than the provider's charge to the general public.
(10) Except in emergency situations,
dispense, render or provide a service or item without a practitioner's written
order and the consent of the recipient or submit a claim for a service or item
which was dispensed or provided without the consent of the recipient.
(11) Except in emergency situations,
dispense, render or provide a service or item to a patient claiming to be a
recipient without first making a reasonable effort to verify by a current
Medical Services Eligibility card that the patient is an eligible recipient
with no other medical resources.
(12) Enter into an agreement, combination or
conspiracy to obtain or aid another in obtaining payment from the Department
for which the provider or other person is not entitled, that is,
eligible.
(13) Make a false
statement in the application for enrollment or reenrollment in the
program.
(14) Commit a prohibited
act specified in §
1102.81(a)
(relating to prohibited acts of a shared health facility and providers
practicing in the shared health facility).
(b) A provider or person who commits a
prohibited act specified in subsection (a), except paragraph (11), is subject
to the penalties specified in §§
1101.76,
1101.77 and
1101.83 (relating to criminal
penalties; enforcement actions by the Department; and restitution and
repayment).
The provisions of this §1101.75 issued under sections
403(a) and (b), 441.1 and 1410 of the Human Services Code (62 P. S.
§§
403(a) and (b),
441.1 and
1410).
This section cited in 55 Pa. Code §
41.153 (relating to burden of
proof and production); 55 Pa. Code §
1101.76 (relating to criminal
penalties); 55 Pa. Code §
1101.83 (relating to restitution
and repayment); 55 Pa. Code §
1101.84 (relating to provider
right of appeal); and 55 Pa. Code §
5221.43 (relating to quality
assurance and utilization review).
