Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part I - Administration › Subpart 5 - Provider Fraud and Recovery › Chapter 41 - Surveillance and Utilization Review Subsystem (SURS) › Subchapter A - General Provisions › Section I-4103 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The following
					 specific terms shall apply to all those participating in the Medicaid Program,
					 either directly or indirectly, and shall be applied when making any and all
					 determinations related to this and other departmental regulations, rules,
					 policies, criteria, and procedures applicable to the Medicaid program and its
					 programs.
Affiliate
- any person who has a direct
						or indirect relationship or association with a provider such that the provider
						is directly or indirectly influenced or controlled by the
affiliate
or has the power to do so. Any person with a direct
						or indirect ownership interest in a provider is presumed to be an
affiliate
of that provider. Any person who shares in the
						proceeds or has the right to share in the proceeds of a provider is presumed to
						be an
affiliate
of that provider unless that person is a
						spouse or a minor child of the provider and has no other affiliation with the
						provider other than that of being a family member of the provider.
Agent
- a person who is employed by or
						has a contractual relationship with a provider or who acts on behalf of the
						provider.
Agreement to Repay
- a formal written
						and enforceable arrangement to repay an identified overpayment, interest,
						monetary penalties or costs and expenses.
Billing Agent
- any agent who performs
						any or all of the provider's billing functions. Billing agents are presumed to
						be an agent of the provider.
Billing or Bill
- submitting, or
						attempting to submit, a claim for goods, supplies, or services.
Claim
- any request or demand, including
						any and all documents or information required by federal or state law or by
						rule made against Medical Assistance Program funds for payment. A claim may be
						based on costs or projected costs and includes any entry or omission in a cost
						report or similar document, book of account, or any other document which
						supports, or attempts to support, the claim. Each claim may be treated as a
						separate claim, or several claims may be combined to form one claim.
Claims
or
Payment
						Review
- the process of reviewing documents or other information or
						sources required or related to the payment or reimbursement to a provider by
						the department, the department's contractor(s), BHSF, SURS, or the fiscal
						intermediary in order to determine if the bill or claim should be or should
						have been paid or reimbursed. Payment and claim reviews are the same
						process.
Contractor
- any person with whom the
						provider has a contract to perform a service or function on behalf of the
						provider. A
contractor
is presumed to be an agent of the
						provider.
Corrective Action Plan
- a written plan,
						short of an administrative sanction, agreed to by a provider, provider-in-fact
						or other person with the department, BHSF, or Program Integrity designed to
						remedy any inefficient, aberrant or prohibited practices by a provider,
						provider-in-fact or other person. A
corrective action
plan is
						not a sanction.
Credible Allegation of Fraud
-
a. an allegation which has been verified by
					 BHSF or Program Integrity, from any source, including, but not limited to the
					 following:
i. fraud hotline
					 complaints;
ii. claims data
					 mining;
iii. patterns identified
					 through provider audits, civil false claims case; and
iv. law enforcement investigations;