Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.5 - Provider Sanctions › Rule 37.85.501 - GROUNDS FOR SANCTIONING

Current through Register Vol. 13, July 5, 2024
(1) Sanctions may
				be imposed by the department against a provider of medical assistance, provided
				under ARM Title 37, chapters 40, 80, 82, 83, 85, 86, 88, 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 under the
				rules of the department.
(c)
				Submitting or causing to be submitted false information for the purpose of
				meeting prior authorization requirements.
(d) Failure to maintain and retain records
				required by the rules of the department.
(e) Failure to disclose or make available
				required records to the department, its authorized agent or other legally
				authorized persons, organizations, or governmental entities.
(f) Failure to provide and maintain services
				to Medicaid recipients at a quality that is within accepted medical community
				standards as adjudged by a body of peers.
(g) Engaging in a course of conduct or
				performing an act which the department's rules or the decision of the
				applicable professional peer review committee, or licensing board, have
				determined to be improper or abusive of the Montana Medicaid program; or
				continuing such conduct following notification that the conduct should
				cease.
(h) Breach of the terms of
				the provider contract or failure to comply with the terms of the provider
				certification on medical assistance claim forms or the failure to comply with
				requirements imposed by the rules of the department.
(i) Over-utilizing the Montana Medicaid
				program by inducing, or otherwise causing a recipient to receive services or
				goods not medically necessary.
(j)
				Rebating or accepting a fee or portion of a fee or charge for a Medicaid
				patient referral.
(k) Violating any
				provision of the state Medicaid law, Title 53, chapter 6, MCA or any rule
				promulgated pursuant thereto, or violating any provision of Title XIX of the
				Social Security Act or any regulation promulgated pursuant thereto.
(l) Submission of a false or fraudulent
				application for provider status.
(m) Violations of any statutes, regulations
				or code of ethics governing the conduct of occupations or professions or
				regulated industries.
(n)
				Conviction of a criminal offense relating to medical assistance programs
				administered by the department or provided under contract with the state; or
				conviction for negligent practice resulting in death or injury to
				patients.
(o) Failure to meet
				requirements of state or federal law for participation (e.g.
				licensure).
(p) Exclusion from the
				Medicare program (Title XVIII of the Social Security Act) because of fraudulent
				or abusive practices.
(q) Charging
				Medicaid recipients for amounts over and above the amounts paid by the
				department for services rendered, except as specifically allowed under ARM
				37.83.825 and
				37.83.826.
(r) Refusal to execute a new provider
				agreement when requested to do so.
(s) Failure to correct deficiencies as
				defined by the ARM or federal regulation after receiving written notice of
				these deficiencies from the department, or the federal Department of Health and
				Human Services. The standards set forth at 42 CFR Part 442, Part 483 and Part
				488, updated through February 2004, which identify deficiencies for providers
				of intermediate care facilities for the mentally retarded, skilled nursing and
				nursing facility services, are incorporated by reference. A copy of 42 CFR Part
				442, Part 483 and Part 488, updated through February 2004, are available from
				the Department of Public Health and Human Services, Quality Assurance Division,
				2401 Colonial Drive, P.O. Box 202653, Helena, MT 59620-2953.
(t) Formal reprimand or censure by an
				association of the provider's peers for unethical practices.
(u) Suspension or termination from
				participation in another government medical program including but not limited
				to workers' compensation, crippled children's services, rehabilitation services
				and Medicare.
(v) Filing of
				criminal indictment, information or complaint for fraudulent billing practices
				or negligent practice resulting in death or injury to the provider's
				patients.
(w) Civil judgement for
				fraudulent billing practices or negligent practice resulting in death or injury
				to the provider's patients.
(x)
				Failure to repay or make acceptable arrangements for the repayment of
				identified overpayments or otherwise erroneous payments.
(y) Threatening, intimidating or harassing
				patients or their relatives in an attempt to influence reimbursement rates or
				affect the outcome of disputes between the provider and the
				department.
(z) Submitting claims
				for reimbursement of costs or services which the provider knows or has reason
				to know are not reimbursable.