New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 351 - SANCTIONS OR REMEDIES › Part 2 - SANCTIONS AND REMEDIES › Section 8.351.2.10 - SANCTIONS

Current through Register Vol. 35, No. 13, July 16, 2024
MAD is required to impose sanctions against a provider for
				  violation of the provisions outlined in the MAD NMAC rules and federal and
				  state laws and regulations. MAD has discretion to impose monetary or
				  non-monetary sanctions against providers for fraud or other forms of
				  misconduct.
A.
Provider
				fraud:
Fraud is the intentional misappropriation, deception or
				misrepresentation made by a provider with the knowledge that the deception
				could result in some unauthorized benefit to the provider, other entity or some
				other person. The term includes any act that constitutes fraud under applicable
				federal or state law or regulation.
B.
Misconduct defined:
Provider
				misconduct includes, but is not limited to, any of the following:
(1) engaging in a course of conduct or
				performing an act that violates any provision of federal or state statutes,
				laws, regulation, and rules, to include HIPAA, or the continuation of his or
				her conduct after the receipt of the notice that the conduct should
				cease;
(2) failure to meet federal
				or state licensing or certification standards required of the provider or other
				entity, including the revocation or suspension of his or her license. The
				provider or other entity must notify MAD of such failure;
(3) failure to correct deficiencies in
				provider or other entity operations within time limits specified by HSD or its
				authorized agent after receiving written notice of these
				deficiencies;
(4) failure to
				maintain and retain any medical, behavioral health or business records as are
				necessary to:
(a) verify the treatment or care
				of a MAP eligible recipient for which the provider or other entity received
				payment from MAD or a HSD contracted MCO to provide the benefit or
				service;
(b) services or goods
				provided to any MAP eligible recipient for which the provider or other entity
				received payment from MAD or a HSD contracted MCO;
(c) amounts paid by MAD or a HSD contracted
				MCO on behalf of a MAP eligible recipient;
(d) identify the practitioners and
				qualifications of practitioners providing the service, and
(e) other records required by MAD for at
				least six years from the date of creation or until ongoing audits are settled,
				whichever is longer;
(5)
				furnishing services to a MAP eligible recipient or billing MAD or a HSD
				contracted MCO for services which fall outside the scope of the provider's
				practice board or outside the scope of his or her prescribed practice or as
				limited by MAD's NMAC rules;
(6)
				failure to comply with the terms of the provider certification, electronic
				signature, or terms of submission for the claim form;
(7) failure to provide complete, accurate,
				and current information on his or her MAD provider participation agreement
				(PPA);
(8) breach of the terms of
				the provider's MAD PPA;
(9) failure
				to provide or maintain services which meet professionally recognized standards
				of care and quality;
(10) engaging
				in negligent or abusive practices which result in death or physical, emotional,
				or psychological injury to a MAP eligible recipient;
(11) failure to repay or make arrangements to
				repay identified overpayments;
(12)
				failure to make records available upon request to HSD or its delegated
				agent;
(13) violation of any laws,
				regulations or code of ethics governing the conduct of providers;
(14) conviction of crimes relating to the
				neglect or abuse of any of his or her patients;
(15) conviction of a felony relating to the
				unlawful manufacture, distribution, prescription or dispensing of a controlled
				substance;
(16) conviction of
				program-related crimes under medicare to include any other programs
				administered by the federal government or any state health care program or the
				suspension or termination of a provider's participation by this or another
				state's medicaid agency;
(17)
				seeking payment for a furnished service or for work related charges and
				penalties from a MAP eligible recipient or his or her personal or authorized
				agent, except as allowed and specifically delineated by HSD;
(18) refusing to furnish services to a MAP
				eligible recipient because he or she has third-party coverage; or
(19) advising a MAP eligible recipient to
				terminate his or her third-party coverage;
(20) failing to follow federal or state
				regulations and rules regarding the management of pain with controlled
				substances, the prescription monitoring program, and prescribing controlled
				substances;
(21) injudicious or
				excessive prescribing;
(22) failing
				to maintain a practitioner-to-patient relationship while prescribing controlled
				substances;
(23) failure of a
				provider or other entity to report overpayments identified by the provider or
				other entity within 60 calendar days of identification which, at that point,
				are presumed to be false claims and are subject to determination as credible
				allegations of fraud.