Florida Administrative Code › 59 - AGENCY FOR HEALTH CARE ADMINISTRATION › 59G - Medicaid › Chapter 59G-9 - OVERSIGHT OF INTEGRITY › Section 59G-9.070 - Administrative Sanctions on Providers, Entities, and Persons

Current through Reg. 50, No. 138; July 16, 2024
(1) Purpose. This rule provides notice of
				administrative sanctions imposed upon a provider, entity, or person for each
				violation of any Medicaid-related law.
(2) Applying and reporting sanctions. Notice
				of the application of sanctions will be by way of written correspondence, and
				the final notice shall be the point of entry for administrative proceedings
				pursuant to Chapter 120, F.S. Satisfaction of an overpayment following a
				preliminary audit report, will not avoid the application of sanctions at a
				final audit report, unless the Agency for Health Care Administration (Agency)
				offers amnesty pursuant to section
				409.913(25)(e),
				F.S. The Agency shall report all sanctions imposed upon any provider, entity,
				or person, or any principal, officer, director, agent, managing employee, or
				affiliated person of a provider, who is regulated by another state entity,
				regardless of whether enrolled in the Medicaid program, to that other state
				entity. Sanctions are imposed upon the Final Order being filed with the Agency
				Clerk.
(3) Definitions.
(a) "Audit report" is the written notice of
				determination that a violation of Medicaid laws has occurred, and where the
				violation results in an overpayment, it also shows the calculation of
				overpayments.
(b) "Claim" is as
				defined in section 409.901(6),
				F.S., and includes the total monthly payment to a provider for per diem
				payments, and the payment of a capitation rate for a Medicaid
				recipient.
(c) "Contemporaneous
				records" means records created at the time the goods or services were provided,
				unless otherwise specified in Medicaid laws, or the laws that govern the
				provider's profession.
(d) A
				"Corrective action plan" is an activity to address the specific areas of
				non-compliance, determined by the Agency, to reduce the risk of future
				non-compliance.
(e) An "Erroneous
				claim" is an application for payment from the Medicaid program, or its fiscal
				agent, that contains an inaccuracy.
(f) "Fine" is a monetary sanction. The amount
				of a fine shall be as set forth within this rule.
(g) A "False claim" is as provided for in the
				Florida False Claims Act, set forth in Chapter 68, F.S.
(h) "Offense" means the occurrence of one or
				more violations as set forth in a final audit report. For purposes of the
				progressive nature of sanctions under this rule, offenses are characterized as
				"first, " "second, " "third, " or "subsequent" offenses; subsequent offenses
				are any occurrences after a third offense.
(i) "Patient record" means the patient's
				medical record, including all documentation maintained by the provider, entity,
				or person to document furnishing, ordering, or authorizing goods or services,
				and includes the documentation in multiple files if the practitioner maintains
				separate files for different types of documentation.
(j) "Patient record request" means a request
				by the Agency for Medicaid-related documentation or information. Such requests
				are not limited to Agency audits to determine overpayments or violations, and
				are not limited to enrolled Medicaid providers. Each requesting document
				constitutes a single patient record request.
(k) "Pattern of erroneous claims" is defined
				as when more than 5% of the claims reviewed are found to contain an error, or
				the reimbursements for the claims found to contain an error, are more than 5%
				of the total reimbursement for the claims reviewed.
(l) "Provider" is as defined in section
				409.901(17),
				F.S., and includes all of the provider's locations that have the same base
				provider number (with separate locator codes).
(m) "Provider group" is more than one
				individual provider practicing under the same tax identification number,
				enrolled in the Medicaid program as a group for billing purposes, and having
				one or more locations.
(n)
				"Sanction" shall be any monetary or non-monetary disincentive imposed pursuant
				to this rule; a monetary sanction may be referred to as a "fine."
(o) "Suspension" is a one-year preclusion
				from furnishing, supervising a person who is furnishing, or causing a person to
				furnish goods or services that result in a claim for payment to the Medicaid
				program. Suspension applies to any person, corporation, partnership,
				association, clinic, group, or other entity, whether or not enrolled in the
				Medicaid program.
(p) "Termination"
				is a twenty-year preclusion from furnishing, supervising a person who is
				furnishing, or causing a person to furnish goods or services that result in a
				claim for payment to the Medicaid program. Termination applies to any person,
				corporation, partnership, association, clinic, group, or other entity, whether
				or not enrolled in the Medicaid program; however, if termination is imposed
				against a provider enrolled in the Medicaid program, the provider agreement
				shall also be terminated. A termination pursuant to this rule is also called a
				"for cause" or "with cause" termination.
(q) "Violation" means any omission or act
				performed by a provider, entity, or person that is contrary to Medicaid laws,
				the laws that govern the provider's profession, or the Medicaid provider
				agreement.
1. For purposes of this rule, each
				day that an ongoing violation continues, and each instance of an act or
				omission contrary to a Medicaid law, a law that governs the provider's
				profession, or the Medicaid provider agreement shall be considered a "separate
				violation."
2. For purposes of
				determining first, second, third, or subsequent offenses under this rule, prior
				Agency actions during the preceding five years will be counted where the
				provider, entity, or person was deemed to have committed the same
				violation.
3. The failure to comply
				with a corrective action plan constitutes a violation, and is an ongoing
				violation, for each day following the deadline for submission of the corrective
				action plan that the failure continues.
4. For purposes of determining a violation
				regarding including an unallowed cost in a cost report (paragraph (7)(k) and
				section 409.913(15)(k),
				F.S.), if the unallowed cost or costs are the subject of an administrative
				hearing pursuant to Chapter 120, F.S., inclusion of the unallowed cost, or
				costs, in a cost report is not a violation until the conclusion of the
				administrative proceedings.
5. For
				purposes of violations under paragraph (7)(n) of this rule, regarding purchase
				shortages (as opposed to shortages of time), each good found to be short, by
				units of each type of goods, such as each tablet of a particular drug, is a
				violation.
6. For purposes of
				violations under paragraph (7)(q) of this rule (generally, non-payment on a
				payment plan), a second, third, or subsequent offense occurs when there has
				been a prior violation on any repayment
				agreement.