Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.20 - SANCTIONS/RECOUPMENTS

Current through 2024-29, July 17, 2024
1.20-1 Grounds for Sanctioning and/or
					 Recouping MaineCare payments from Providers, Individuals or Entities
The Department may impose sanctions and/or recoup
						identified overpayments against a provider, individual, or entity for any one
						or more of the following reasons:
A.
					 Presenting or causing to be presented for payment any false or fraudulent claim
					 for services or merchandise;
B.
					 Submitting or causing to be submitted false information for the purpose of
					 obtaining greater compensation than that to which the provider is legally
					 entitled;
C. Submitting or causing
					 to be submitted false information for the purpose of meeting prior
					 authorization requirements;
D.
					 Failing to retain or disclose or make available to the Department or its
					 Authorized Entity contemporaneous records of services provided to MaineCare
					 members and related records of payments;
E. Failing to provide and maintain quality
					 services to MaineCare members within accepted principles and values of medical
					 professionalism and national standards of care;
F. Engaging in a course of conduct or
					 performing an act deemed improper, abuse of the MaineCare Program, or
					 continuing such conduct following notification that said conduct should cease;
Examples of such abusive acts include, but are not
						limited to, the following:
1.
					 Furnishing services or supplies which are determined by the Department to be
					 substantially in excess of the needs of, or harmful to, individuals, or to be
					 of inferior quality, or not of usual or customary quality;
2. Soliciting or accepting from a member, his
					 or her family, friend or other representative an amount over and above the
					 reasonable charge amount or fee schedule for covered services
					 (supplementation);
3. Maintaining a
					 separate schedule of charges for MaineCare and non-MaineCare patients that
					 results in higher charges for MaineCare than for non-MaineCare
					 patients;
4. Billing based on
					 "gang" visits, (for example, a dental provider in a school setting, or a
					 physician visits a nursing home, walks through the facility, and bills for
					 individual nursing home visits, without rendering any specific service to
					 individual patients).
G.
					 Breaching the terms of the MaineCare Provider Agreement, and/or the
					 Requirements of Section 1.03-8 for provider participation;
H. Over utilizing MaineCare by inducing,
					 furnishing, or otherwise causing a member to receive service(s) or merchandise
					 not otherwise required or requested by the member;
I. Rebating or accepting a fee or portion of
					 a fee or charge for a MaineCare member referral (kickback);
J. Physician self-referrals determined to be
					 in violation of Title XVIII, § 1877 of the
Social Security
					 Act
(
					 42 U.S.C. §
													1395nn ), which prohibits certain physician
					 self-referrals for designated health services, and
					 42 C.F.R.
					 §§
													1001.951 /952 and
					 42
					 C.F.R. §
													411.353.
Designated health services include any of the following
						items or services:
1. Clinical
					 laboratory services;
2. Physical
					 therapy services;
3. Occupational
					 therapy services;
4. Radiology
					 services, including MRIs, CAT scans, and ultrasound services;
5. Radiation therapy services and
					 supplies;
6. Durable medical
					 equipment and supplies;
7.
					 Parenteral and enteral nutrients, equipment, and supplies;
8. Prosthetics, orthotics, and prosthetic
					 devices and supplies;
9. Home
					 health services;
10. Outpatient
					 prescription drugs;
11. Inpatient
					 and outpatient hospital services; and
12. Speech-language pathology
					 services
K.  Violating the
					 applicable provision of any law governing benefits governed by this Manual, or
					 any rule or regulation promulgated pursuant thereto;
L. Submission of a false or fraudulent
					 application for provider status;
M
					 Violation of any laws, regulations or code of ethics governing the conduct of
					 occupations or professions or regulated industries;
N. Conviction of a criminal offense relating
					 to performance of a Provider Agreement with the State, negligent practice
					 resulting in death or injury to patients, or misuse or misapplication of
					 program funds;
O. Failure to meet
					 standards required by state or federal law for participation (e.g. licensure or
					 certification requirements);
P.
					 Documented practice of charging members for services over and above the amount
					 paid by the Department and/or charging members for services prior to receipt of
					 MaineCare payments;
Q. Failure to
					 correct deficiencies in provider operations in accordance with an accepted plan
					 of correction after receiving written notice of these deficiencies from the
					 Department;
R. Formal reprimand or
					 censure by an association of the provider's peers for unethical
					 practices;
S. Suspension, exclusion
					 or termination from participation in another governmental medical program, such
					 as Medicare, Workers' Compensation, Children With Special Health Needs Program,
					 and Rehabilitation Services, for fraudulent or abusive practices;
T. Conviction for fraudulent billing
					 practices, negligent practice, or patient abuse;
U. Failure to repay or make arrangements to
					 repay overpayments or payments made in error;
V. Failure to return money paid by members to
					 a provider for covered services rendered during any period of MaineCare
					 eligibility, including failing to pay back members for services for which they
					 were charged when they have eligibility determined retroactively and there is
					 evidence of notification of retroactive eligibility for the member;
W. Unauthorized use of a primary care
					 provider's MaineCare Identification number as described in Section
					 1.03-8;
X. Breach of the terms of
					 legal and binding contract(s) with contractor(s) or subcontractor(s) who
					 provide their contractual services to MaineCare members; or Y. Failure to abide
					 by the provisions of 42 C.F.R. § 1000
et seq
., pertaining
					 to the exclusion of individuals and entities;
Z. For an organization or entity that is an
					 HMO or any entity furnishing services under a waiver approved under
					 42 U.S.C. §
													1396n(b)(1), having a
					 substantial contractual relationship with an individual or entity that could be
					 excluded. A substantial contractual relationship is one in which the sanctioned
					 individual or entity has direct or indirect business transactions to more than
					 $25,000 or five percent (5%) of the organization or entity's total operating
					 expenses, whichever is less. Business transactions include but are not limited
					 to contracts, agreements, purchase orders or leases to obtain services,
					 supplies, equipment, space or salaried employment; and
AA. Conviction of a crime that occurred while
					 performing services as a health care worker or provider.
BB. Failure to provide information to the
					 Department or to otherwise respond to Departmental requests for information
					 within a reasonable timeframe established by the Department.