Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-60 - PROVIDER BASED RURAL HEALTH CLINIC REIMBURSEMENT › Section 560-X-60-.16 - Negligence And Fraud Penalties

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Whenever an overpayment of Medicaid
			 reimbursement received by a provider from Medicaid results from the negligent
			 or intentional disregard of Medicaid Reimbursement Principles by the provider
			 or its representatives (but without intent to defraud), there will be deducted
			 from any reimbursement thereafter due the provider a penalty equal to 5% of
			 such overpayment.
(2) If any part
			 of such an overpayment by Medicaid to the provider is due to fraud on the part
			 of the provider or any of its representatives, there will be deducted from any
			 subsequent reimbursement due the provider on proof of fraud, a penalty equal to
			 50% of the overpayment.
(3) The
			 penalties imposed under Rules No.
			 560-X-60-.16(l) and
			 (2) of this Code shall be in addition to and
			 shall in no way affect Medicaid's right to also recover the entire amount of
			 the overpayment caused by the provider's or its representative's negligence or
			 intentional disregard of the Medicaid Reimbursement Principles or
			 fraud.
(4) Whenever the cost of a
			 good or service has been previously disallowed as the result of a desk audit of
			 a provider's cost report and/or a field audit by Medicaid and such cost has not
			 been reinstated by voluntary action of Medicaid as the result of an
			 administrative hearing, or by a court order, such costs shall not thereafter be
			 included as an allowable cost on a Medicaid cost report. The inclusion by the
			 provider or its representative of such a cost on a subsequent cost report,
			 unless the provider is actively pursuing an administrative or judicial review
			 of such disallowance, will be considered as negligent and/or intentional
			 disregard of the Medicaid Reimbursement Principles and subject to the 5%
			 penalty imposed by Rule No.
			 560-X-60-.16(1)
			 of this Code based upon the amount of overpayment which has or which would have
			 resulted from the inclusion of such cost had its inclusion not been detected.
			 Such inclusion shall also be subject to the provisions of Rule No.
			 560-X-60-.17 relating to
			 intentional or negligent disregard of the Medicaid Reimbursement
			 Principles.
(5) For purposes of the
			 preceding paragraph, a provider shall be considered as having included a
			 previously disallowed cost on a subsequent year's cost report if the cost
			 included is attributable to the same type good or service under substantially
			 the same circumstances as that which resulted in the previous disallowance.
			 Examples of such prohibited inclusions include, but are not limited to:
(a) Inclusion of the portion of rental
			 payment previously disallowed as being between related parties.
(b) Inclusion of an amount of compensation
			 which has previously been disallowed as unreasonable during a prior
			 period.
(c) Inclusion of a cost not
			 related to patient care which has previously been disallowed.
(d) Improper classification or allocation of
			 costs to cost clinics.