Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 79 - Other Policies Relating to Providers of Medical and Remedial Care › Rule 441-79.2 - Sanctions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Definitions.
"Affiliates "
means persons having an overt
				  or covert relationship such that any one of them directly or indirectly
				  controls or influences or has the power to control or influence another.
"Iowa Medicaid enterprise"
means the entity
				  comprised of department staff and contractors responsible for the management
				  and reimbursement of Medicaid services for the benefit of Medicaid
				  members.
"Person"
means any individual human being or
				  any company, firm, association, corporation, institution, or other legal
				  entity. "Person" includes but is not limited to a provider and any affiliate of
				  a provider.
"Probation "
means a specified period of
				  conditional participation in the medical assistance program.
"Provider"
means an individual human being,
				  firm, corporation, association, institution, or other legal entity, which is
				  providing or has been approved to provide medical assistance to a member
				  pursuant to the state medical assistance program.
"Suspension from participation "
means an
				  exclusion from participation for a specified period of time.
"Suspension of payments"
means the temporary
				  cessation of payments due a person until the resolution of a matter in dispute
				  between a person and the department.
"Termination from participation "
means a
				  permanent exclusion from participation in the medical assistance
				  program.
"Withholding of payments"
means a reduction
				  or adjustment of the amounts paid to a person on pending and subsequently
				  submitted bills for purposes of offsetting payments made to, received by, or in
				  the possession of a person.
(2)
Grounds for sanctions.
The department may impose sanctions against any person when appropriate.
				Appropriate grounds for the department to impose sanctions include, but are not
				limited to, the following:
a. Presenting or
				causing to be presented for payment any false, intentionally misleading, or
				fraudulent claim for services or merchandise.
b. Submitting or causing to be submitted
				false, intentionally misleading, or fraudulent information for the purpose of
				obtaining greater compensation than that to which the person is legally
				entitled, including charges in excess of usual and customary charges.
c. Submitting or causing to be submitted
				false, intentionally misleading, or fraudulent information for the purpose of
				meeting prior authorization or level of care requirements.
d. Upon lawful demand, failing to disclose or
				make available to the department, the department's authorized agent, any law
				enforcement or peace officer, any agent of the department of inspections and
				appeals' Medicaid fraud control unit, any agent of the auditor of state, the
				Iowa department of justice, any false claims investigator as defined under Iowa
				Code chapter 685, or any other duly authorized federal or state agent or agency
				records of services provided to medical assistance members or records of
				payments made for those services.
e. Failing to provide or maintain quality
				services, or a requisite assurance of a framework of quality services to
				medical assistance recipients within accepted medical community standards as
				adjudged by professional peers if applicable. For purposes of this subrule,
				"quality services" means services provided in accordance with the applicable
				rules and regulations governing the services.
f. Engaging in a course of conduct or
				performing an act which is in violation of any federal, state, or local
				statute, rule, regulation, or ordinance, or an applicable contractual
				provision, that relates to, or arises out of, any publicly or privately funded
				health care program, including but not limited to any state medical assistance
				program.
g. Submitting a false,
				intentionally misleading, or fraudulent certification or statement, whether the
				certification or statement is explicit or implied, to the department or the
				department's representative or to any other publicly or privately funded health
				care program.
h. Overutilization of
				the medical assistance program by inducing, furnishing or otherwise causing a
				member to receive services or merchandise not required or requested.
i. Violating any provision of Iowa Code
				chapter 249A, or any rule promulgated pursuant thereto, or violating any
				federal or state false claims Act, including but not limited to Iowa Code
				chapter 685.
j. Submitting or
				causing to be submitted false, intentionally misleading, or fraudulent
				information in an application for provider status under the medical assistance
				program or any quality review or other submission required to maintain good
				standing in the program.
k.
				Violating any law, regulation, or code of ethics governing the conduct of an
				occupation, profession, or other regulated business activity, when the
				violation relates to, or arises out of, the delivery of services under the
				state medical assistance program.
l. Breaching any settlement or similar
				agreement with the department, or failing to abide by the terms of any
				agreement with any other entity relating to, or arising out of, the state
				medical assistance program.
m.
				Failing to meet standards required by state or federal law for participation,
				including but not limited to licensure.
n. Exclusion from Medicare or any other state
				or federally funded medical assistance program.
o. Except as authorized by law, charging a
				person for covered services over and above what the department paid or would
				pay or soliciting, offering, or receiving a kickback, bribe, or rebate, or
				accepting or rebating a fee or a charge for medical assistance or patient
				referral, or a portion thereof. This ground does not include the collection of
				a copayment or deductible if otherwise allowed by law.
p. Failing to correct a deficiency in
				provider operations after receiving notice of the deficiency from the
				department or other federal or state agency.
q. Formal reprimand or censure by an
				association of the provider's peers or similar entity related to professional
				conduct.
r. Suspension or
				termination for cause from participation in another program, including but not
				limited to workers' compensation or any publicly or privately funded health
				care program.
s. Indictment or
				other institution of criminal charges for, or plea of guilty or nolo contendere
				to, or conviction of, any crime punishable by a term of imprisonment greater
				than one year, any crime of violence, any controlled substance offense, or any
				crime involving an allegation of dishonesty or negligent practice resulting in
				death or injury to a provider's patient.
t. Violation of a condition of probation,
				suspension of payments, or other sanction.
u. Loss, restriction, or lack of hospital
				privileges for cause.
v. Negligent,
				reckless, or intentional endangerment of the health, welfare, or safety of a
				person.
w. Billing for services
				provided by an excluded, nonenrolled, terminated, suspended, or otherwise
				ineligible provider or person.
x.
				Failing to submit a self-assessment, corrective action plan, or other
				requirement for continued participation in the medical assistance program, or
				failing to repay an overpayment of medical assistance funds, in a timely
				manner, as set forth in a rule or other order.
y. Attempting, aiding or abetting,
				conspiring, or knowingly advising or encouraging another person in the
				commission of one or more of the grounds specified herein.