Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 20 - Medicaid Payments and Providers › Subchapter 00 - N/A › Part 1 - Medicaid Payments and Providers › Section 210-RICR-20-00-1.10 - Medicaid Provider Administrative Sanctions

Current through June 14, 2024
A. In
				  accordance with R.I. Gen. Laws Chapters 42-35 (The Administrative Procedures
				  Act), and 40-8.2, the EOHHS is authorized to establish administrative
				  procedures to impose sanctions on providers of health services and supplies for
				  any violation of the Rules, Regulations, standards, or laws governing the Rhode
				  Island Medicaid Program. The Federal Government mandates the development of
				  these administrative procedures for the Title XIX Medicaid Program in order to
				  ensure compliance with §§
										1128  and  1128A   of the Social Security Act,
				   42 U.S.C. §§
											1320a-7 and  1320a-7a, which imposes Federal penalties
				  for certain violations.
B.
				  Sanctionable Violations. All providers of Medicaid and CHIP-funded health care
				  services and supplies are subject to the R.I. Gen. Laws and the Rules and
				  Regulations governing the Medicaid program. Sanctions may be imposed by the
				  EOHHS against a Medicaid provider for any one (1) or more of the following
				  violations of applicable law, Rule, or Regulation:
1. Presenting or causing to be presented for
				  payment any false or fraudulent claim for medical services or
				  supplies.
2. Submitting or causing
				  to be submitted false information for the purpose of obtaining greater
				  compensation than to which the provider is legally entitled.
3. Submitting or causing to be submitted
				  false information for the purpose of meeting prior authorization
				  requirements.
4. Failure to
				  disclose or make available to the Single State Agency or its authorized agent
				  records of services provided to Medicaid recipients and records of payments
				  made for such services.
5. Failure
				  to provide and maintain quality services to Medicaid recipients within accepted
				  medical community standards as determined by an official body of
				  peers.
6. Engaging in a course of
				  conduct or performing an act deemed improper or abusive of the Medicaid Program
				  or continuing such conduct following notification that said conduct should
				  cease.
7. Breach of the terms of a
				  Medicaid provider agreement or failure to comply with the terms of the provider
				  certification of the Medicaid claim form.
8. Overutilizing the Medicaid Program by
				  inducing, furnishing, or otherwise causing a beneficiary to receive services or
				  supplies not otherwise required or requested by the beneficiary.
9. Rebating or accepting a fee or portion of
				  a fee or charge for a Medicaid beneficiary referral.
10. Violating any provisions of applicable
				  Federal and State laws, Regulations, plans, or any Rule or Regulation
				  promulgated pursuant thereto.
11.
				  Submission of false or fraudulent information in order to obtain provider
				  status.
12. Violations of any laws,
				  Regulations, or code of ethics governing the conduct of occupations or
				  professions or regulated industries.
13. Any disqualifying conviction.
14. Failure to meet standards required by
				  State or Federal laws for participation such as licensure and
				  certification.
15. Exclusion from
				  the Federal Medicare program or any State health care program administered by
				  the EOHHS because of fraudulent or abusive practices.
16. A practice of charging beneficiaries or
				  anyone acting on their behalf for services over and above the payment made by
				  the Medicaid Program, which represents full and total payment.
17. Refusal to execute a provider agreement
				  when requested to do so.
18.
				  Failure to correct deficiencies in provider operations after receiving written
				  notice of these deficiencies from the Single State Agency.
19. Formal reprimands or censure by an
				  association of the provider's peers for unethical practices.
20. Suspension or termination from
				  participation in another governmental health care program under the auspices of
				  Workers' Compensation, Office of Rehabilitation Services, Medicare, or any
				  State program administered by the EOHHS or one of the agencies under the EOHHS
				  umbrella.
21. Indictment for
				  fraudulent billing practices or negligent practice resulting in death or injury
				  to the provider's patients.
22.
				  Failure to produce records as requested by the State Agency.
23. Failure to repay or make arrangement for
				  the repayment of identified overpayments or otherwise erroneous
				  payments.