Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.10-007 - Section I Provider Manual Update Transmittal

Current through Register Vol. 49, No. 6, June, 2024
142.500 Conditions Related to Fraud and Abuse
A. Any provider who engages in fraudulent
			 billing practices will be immediately suspended from participation until these
			 practices are evaluated and resolved. Also, any provider discovered to be
			 involved in fraudulent billing practices or found to be accepting or soliciting
			 unearned rebates, refunds or other unearned considerations, whether in the form
			 of money or otherwise, will be referred to the appropriate legal agency for
			 prosecution under applicable federal or state laws.
B. Any provider who engages in abuse or
			 over-utilization of services provided to Medicaid beneficiaries, when such
			 abuse or over-utilization has been determined by DMS professional staff,
			 medical consultants, contractors or designees, may be terminated from
			 participation in the Medicaid Program, required to repay monies paid by the
			 Medicaid Program for such services or have other appropriate action taken upon
			 recommendation of the above-referenced parties.
C. Except where participation has been
			 terminated, each provider who has been sanctioned may be required to
			 participate ina provider education program as a condition of continued
			 participation. Provider education programs will include, at a minimum, the
			 following:
1. Instruction on admissions and
			 authorization for payments
2.
			 Instruction on the use and format of required program forms
3. Instruction on key provisions of the
			 Medicaid Program
4. Instruction on
			 reimbursement rates
5. Instruction
			 on how to inquire about program requirements, payment or billing problems and
			 the overall operation of the program
D. Providers are obligated to screen all
			 employees and contractorsto determine; if any of them are excluded from
			 participation in Federal health care programs.
1. Providers can search the LEIE website
			 maintained by the United States Health and Human Services Office of Inspector
			 General which contains the names of any excluded individual or, entity.
(
http://www.oia.hhs.aov/fraud/exclusions.asp
).
				The United States Genercal Services Administration maintains a list of excluded
				providers at
https://www.epls.gov/
.
				Providers should search the website monthly |q capture exclusions and
				reinstatements that have occurred since the last search. .
2. Providers can find a Department of Human
			 Services excluded list on the Arkansas Department of Human Services website at:
https://ardhs.sharepointsite.net/ExcludedProvidersList/Excluded%20Provided%20List.html
.
			 This list contains the names of any excluded individuals or entities. The
			 Arkansas Department of Finance and Administration, Office of State Procurement,
			 maintains a list of suspended or debarredivendprstat:
http://www.dfa.arkansas.aov/offices/procurement/auidelines/Paqes/suspendedDebarredVendors.aspx
3. If providers discover any exclusion
			 information other that what is provided on the websites, providers should
			 report that information to Provider Enrollment.
4. Providers should check the websites
			 monthly to capture exclusions and reinstatements which may have occurred since
			 the last search.
E. No
			 Medicaid payments can be made for any times or services directed or prescribed
			 by an excluded provider; or any other authorized person, when the individual
			 entity furnishing the services knew or should have known of the exclusion. This
			 prohibition applies even when the Medicaid payment itself is made to another
			 provider, practitioner or supplier that is not excluded. (See
			 42 CFR section
			 1001.1901(b) ).The following
			 listing sets forth examples of types of services that are reimbursed by
			 Medicaid which, when provided by excluded parties, are not reimbursable:
1. Nurses, technicians or other excluded
			 individuals who work for a hospital, nursing home, home health agency or
			 physician practice, where such services are related to administrative duties,
			 preparation of surgical trays or review of treatment plans if such services are
			 reimbursed directly or indirectly by a Medicaid program, even if the
			 individuals do not furnish direct medical care to Medicaid
			 beneficiaries.
2. Services
			 performed by excluded pharmacists or other excluded individuals who input
			 prescription information for pharmacy billing or who-are involved in any way
			 infilling prescriptions for drugs reimbursed directly or indirectly by a
			 Medicaid program.
3. Services
			 performed by excluded ambulance drivers, dispatchers or other employee's
			 patients or nursing home residents.
4. Services performed for program
			 beneficiaries by excluded individuals who sell, deliver or refill orders for
			 medical'devices or equipment being reimbursed by a Medicaid program.
5. Services performed by excluded social
			 workers who are employed by health care entities to provide services to
			 Medicaid beneficiaries and whose services are reimbursed, directly or
			 indirectly by a Medicaid program.
6. , Services performed by an excluded
			 administrator, billing agent, accountant,
claims processor or utilization reviewer that are related to
				and reimbursed, directly or indirectly by a Medicaid program.
7. Items or services provided to a Medicaid
			 beneficiary by an excluded individual who works for an entity that has a
			 contractual agreement with, and is paid by, a Medicaid program.
8. Items or equipment "sold by an excluded
			 manufacturer or supplier, used in the care or treatment of beneficiaries and
			 reimbursed, directly or indirectly by a Medicaid program.
F. Civil monetary penalties may be imposed
			 against Medicaid providers who employ or enter into contracts with excluded
			 individuals or entities to provider items or services to Medicaid
			 beneficiaries. (See 1128A (a) (6) of the Act and
			 42 CFR
			 section 1003.102(a)
			 (2).)