Current through Reg. 49, No. 38; September 20, 2024
A person is subject to administrative actions or
sanctions if the person:
(1) fails to
make, maintain, retain, or produce adequate documentation according to Medicaid
or other HHS policy, state or federal law, rule or regulation, or contract for
a minimum period of:
(A) five years from the
date of service or until all audit questions, administrative hearings,
investigations, court cases, or appeals are resolved;
(B) six years or until all audit questions,
administrative hearings, investigations, court cases, or appeals are resolved
if the person is a Freestanding Rural Health Clinic; and
(C) ten years or until all audit questions,
administrative hearings, investigations, court cases, or appeals are resolved
if the person is a hospital-based Rural Health Clinic;
(2) fails to provide originals or complete
and correct copies of records or documentation as requested upon reasonable
request by a requesting agency ; or
(3) fails to grant immediate access to the
premises, records, documentation, or any items or equipment determined
necessary by the OIG to complete its official functions related to a fraud,
waste, or abuse investigation upon request by a requesting agency . Failure to
grant immediate access may include, but is not limited to, the following:
(A) failure to allow the OIG or any
requesting agency to conduct any duties that are necessary to the performance
of their official functions;
(B)
failure to provide to the OIG or a requesting agency , upon request and as
requested, for the purpose of reviewing, examining, and securing custody of
records, access to, disclosure of, and custody of copies or originals of any
records, documents, or other requested items, as determined necessary by the
OIG or a requesting agency to perform official functions;
(C) failure to produce or make available
records within 24 hours of a request for production, for the purpose of
reviewing, examining, and securing custody of records upon reasonable request,
as determined by the OIG or a requesting agency except where the OIG or a
requesting agency reasonably believes that requested documents are about to be
altered or destroyed or that the request may be completed at the time of the
request and/or in less than 24 hours;
(D) failure to grant access to a person's
premises at the time of a reasonable request;
(E) failure to provide access to records at
the time of a request, for the purpose of reviewing, examining, and securing
custody of records upon reasonable request, when the OIG or a requesting agency
has reason to believe that:
(i) requested
documents are about to be altered or destroyed; or
(ii) in the opinion of the OIG or a
requesting agency , the request could be met at the time of the request or in
less than 24 hours;
(F)
failure to relinquish custody of records and documents as directed by the OIG
or a requesting agency ;
(G)
failure to complete a records affidavit, business records affidavit, evidence
receipt, or patient record receipt, at the direction of the OIG or a requesting
agency and to attach these documents to the records or documentation requested;
or
(4) fails to make,
maintain, retain, or produce documentation sufficient to demonstrate compliance
with any federal or state law, rule, regulation, contract, Medicaid or other
HHS policy, or professional standard in order to:
(A) participate in the Medicaid or other HHS
program;
(B) support a claim for
payment;
(C) verify delivery of
services or items provided;
(D)
establish medical necessity, medical appropriateness, or adherence to the
professional standard of care related to services or items provided;
(E) determine appropriate payment for items
or services delivered in accordance with established rates;
(F) confirm the eligibility of a person to
participate in the Medicaid or other HHS program;
(G) demonstrate solvency of risk-bearing
providers;
(H) support a cost or
expenditure;
(I) verify the
purchase and actual cost of products, items, or services; or
(J) establish compliance with applicable
state and federal regulatory requirements.
