Current through Register Vol. 24-18, September 15, 2024
(1) The medicaid agency (agency) requires any
entity (including providers) that makes or receives medical assistance payments
from the agency or the agency desig-nee of at least $5,000,000 annually under
the state plan to meet the requirements of Section 1902 (a)(68) of the Social
Security Act in order to receive payments.
(2)
Entity policies and
procedures. Entities must adopt and disseminate policies and procedures
for their employees, contractors, and agents regarding federal and state false
claims and whistleblower protection laws.
(a)
Written policies and procedures may be in paper or electronic form, but must be
readily available to all employees, contractors, and agents.
(b) If the entity has an employee handbook,
it must include a specific discussion of the laws described in written policies
regarding the rights of employees to be protected as whistleblowers, and a
specific discussion of the entity's policies and procedures for detecting and
preventing fraud, waste, and abuse.
(3)
Entity. An "entity" may
include, but is not limited to, individual providers, a governmental agency,
organization, unit, corporation, partnership, or other business arrangement
irrespective of the form of business structure by which it exists or whether
for-profit or not-for-profit.
(a) An
organization may have multiple subsidiaries, locations, federal employer
identification numbers (FEIN), or provider numbers and still be combined for
the purposes of meeting the definition of an entity.
(b) Whether subsidiaries would be aggregated
or viewed as separate entities depends on the corporate structure and
assessment of the largest separate organizational unit that furnishes medicaid
health care items or services.
(c)
The agency and its designee administering the medic-aid program, or any agent
performing an administrative function, are not considered entities.
(4)
Payments
received. For any entity that receives medical assistance payments under
the state plan of at least $5,000,000 annually, the total amount includes:
(a) All payments received by an entity who
furnishes items or services at one or more location(s);
(b) All payments received by an entity who
furnishes items or services under one or more contractual or other payment
arrangement(s);
(c) Only the
amounts received from the agency or the agency designee. The amounts paid by a
managed care organization (MCO) to the entity are only counted against the MCO,
not the entity, when calculating the $5,000,000 threshold; and
(d) Only payments received from Washington
state. Payments from multiple states are not aggregated to reach the $5,000,000
annual threshold.
(5)
Annual monitoring. At the conclusion of each federal fiscal year,
the agency identifies who qualifies as an entity subject to the requirements in
Section 1902 (a)(68) of the Social Security Act.
(a) If the agency determines that an entity
is subject to and must comply with Section 1902 (a)(68) of the act:
(i) The agency provides written notice to the
entity that it must comply;
(ii)
The entity must submit an attestation to the agency under penalty of perjury to
verify the entity has adopted and disseminated compliant, written policies as
required; and
(iii) The agency may
request copies of the written policies and proof of dissemination to verify
compliance with the requirements.
(b) If the agency does not receive the
required documentation by the due date, the agency sends a warning to the
entity to become compliant by a specified deadline.
(c) If the entity remains noncompliant after
the deadline, the agency ceases medical assistance payments until the entity is
compliant.
