Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 3 - Provider Sanctions and Remedies › 7 AAC 105.400 - Grounds for sanctioning providers

Current through May 31, 2024
The department may impose sanctions for one or more of the
					 following reasons:
(1) presenting or
				  causing to be presented for payment any false or fraudulent claim for services
				  or supplies;
(2) submitting or
				  causing to be submitted false information for the purpose of obtaining greater
				  compensation than that to which the provider is legally entitled, including
				  charges in excess of a rate established by the department or the provider's
				  usual and customary charges;
(3)
				  submitting or causing to be submitted false information for the purpose of
				  meeting prior authorization requirements;
(4) failing to disclose or make available to
				  the department records of services provided to Medicaid recipients and records
				  of payments made for them;
(5)
				  failing to provide and maintain quality services to Medicaid recipients within
				  accepted medical community standards as adjudged by a body of professional
				  peers equivalently licensed to practice in this state;
(6) engaging in a course of conduct or
				  performing an act the department considers deceptive or abusive of the Medicaid
				  program or continuing that conduct following notification that it should
				  cease;
(7) breaching the terms of
				  the Medicaid provider agreement or failure to comply with the terms of the
				  provider certification on the Medicaid claims form;
(8) overusing the Medicaid program by
				  inducing, or otherwise causing, a recipient to receive services or supplies not
				  required or requested by the recipient;
(9) rebating or accepting a fee or portion of
				  a fee or charge for a Medicaid recipient referral;
(10) violating any provision of AS 47.07 or
				  any regulation adopted under it;
(11) submitting a false or fraudulent
				  application for provider status;
(12) violating any law or code of ethics
				  governing the conduct of relevant occupations, professions, or regulated
				  industries;
(13) being convicted of
				  a criminal offense relating to performance of a provider agreement with the
				  state or found liable for a negligent act resulting in death or injury to a
				  recipient;
(14) failing to meet
				  standards required by state or federal law for participation, including
				  licensure;
(15) being excluded from
				  the Medicare program because of fraudulent or abusive practices;
(16) following a documented practice of
				  charging recipients for Medicaid services in an amount above the payment made
				  by the department for that Medicaid service;
(17) refusing to execute a new provider
				  agreement when requested to do so;
(18) failing to correct deficiencies in
				  provider operations after receiving written notice of these deficiencies from
				  the department;
(19) being formally
				  reprimanded or censured by an association of the provider's peers for unethical
				  practices;
(20) being suspended or
				  terminated from participation in another governmental medical program such as
				  worker's compensation under AS 23.30, vocational rehabilitation services under
				  AS
				  23.15.010-
				  23.15.210,
				  and Medicare;
(21) failing to repay
				  or make arrangements for repaying
(A) an
				  identified overpayment or otherwise erroneous Medicaid payment under 7 AAC 105
				  - 7 AAC 160; or
(B) an electronic
				  health record incentive payment if the department requires repayment under
				  7 AAC 165.050(d) (2);