North Dakota Administrative Code › Title 75 - Department of Human Services › Article 75-02 - Economic Assistance › Chapter 75-02-05 - Provider Integrity › Section 75-02-05-05 - Grounds for sanctioning providers

Current through Supplement No. 393, July, 2024
Sanctions may be imposed by the department against a provider
				  who:
1. Presents or causes to be
				presented for payment any false or fraudulent claim for care or
				services.
2. Submits or causes to
				be submitted false, intentionally misleading, or fraudulent information for the
				purpose of obtaining greater compensation than that to which the provider is
				legally entitled.
3. Submits or
				causes to be submitted false, intentionally misleading, or fraudulent
				information for the purpose of meeting prior authorization or level of care
				requirements.
4. Submits or causes
				to be submitted false, intentionally misleading, or fraudulent information in
				an application status for provider status under the Medicaid or children's
				health insurance program or any quality review or other submission required to
				maintain enrollment.
5. Fails to
				disclose or make available to the department or its authorized agent records of
				services provided to Medicaid and children's health insurance program
				recipients and records of payments received for those services; or fails to
				make available records from the provider's practice that allows department
				staff to evaluate overall scheduling, patient-to-provider ratios, review
				billing practices, or evaluate the feasibility of services provided per
				day.
6. Submits a false,
				intentionally misleading, or fraudulent certification or statement, whether the
				certification or statement is explicit or implied, to the department or
				department's representative or to any other publicly or privately funded health
				care program.
7. Fails to provide
				and maintain services to Medicaid and children's health insurance program
				recipients within accepted medical and industry standards. Failing to provide
				or maintain quality services, or a requisite assurance of a framework of
				quality services to Medicaid and children's health insurance program recipients
				within accepted medical community standards as adjudged by professional peers,
				if applicable. For purposes of this subsection, "quality services" mean
				services provided in accordance with the applicable rules and regulations
				governing the services.
8. Fails to
				comply with the terms of the Medicaid provider agreement or provider
				certification which is printed on the Medicaid claim form.
9. Overutilizes the Medicaid and children's
				health insurance program by inducing, furnishing, or otherwise causing a
				recipient to receive care and services that are not medically
				necessary.
10. Rebates or accepts a
				fee or portion of a fee or charge for a Medicaid and children's health
				insurance program patient referral.
11. Is convicted of a criminal offense
				arising out of the practice of medicine.
12. Fails to comply and to maintain
				compliance with all regulations and statutes, both state and federal, which are
				applicable to the provider's profession, business, or enterprise.
13. Is excluded from Medicare.
14. Is suspended, excluded from
				participation, terminated, or sanctioned by any other state's Medicaid and
				children's health insurance program.
15. Is suspended or involuntarily terminated
				from participation in any governmentally sponsored medical program.
16. Bills or collects from the recipient any
				amount in violation of section
				75-02-05-04.
17. Fails to correct deficient provider
				operations within a reasonable time, not to exceed thirty days, after receiving
				written notice of these deficiencies from the department, another responsible
				state agency, or their designees.
18. Is formally reprimanded or censured by an
				association of the provider's peers for unethical practices.
19. Fails to change or modify delivery
				patterns and services within a reasonable period after receipt of a request so
				to do by a peer review committee whose jurisdiction includes the
				provider.
20. Is convicted of a
				criminal offense arising out of the making of false or fraudulent statements or
				of an omission of fact for the purpose of securing any governmental benefit to
				which the provider is not entitled, or out of conspiring, soliciting, or
				attempting such an action.
21.
				Refuses to repay or make arrangements for the repayment of identified
				overpayments or otherwise erroneous payments. A refusal of repayment exists if
				no repayment or arrangement for repayment is made within thirty days of the
				date written notice of discrepancy was sent.
22. Is served with a search warrant by a
				member of any law enforcement agency for the purpose of obtaining evidence of a
				crime of fraud committed by that provider against the Medicaid or children's
				health insurance program, or is charged with such a crime, provided that no
				provider may be terminated from participation in the Medicaid or children's
				health insurance program on such grounds.
23. Refuses to attend a department
				educational program or fails to agree to implement a business integrity
				agreement, if required by the department.
24. Defrauds any health care benefit
				program.
General Authority:
NDCC 50-06-1.9, 50-24.1-04,
					 50-29-02
Law Implemented:
NDCC 12.1-11-02;
					 42 CFR
					 455.13, 42 CFR 455.16,
					 42 CFR
					 431.107