Oregon Administrative Rules › Chapter 333 - OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION › Division 10 - HEALTH PROMOTION AND CHRONIC DISEASE PREVENTION › Section 333-010-0280 - Provider Sanctions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Center
			 may sanction an enrolling provider if the provider:
(a) Is convicted of a felony or misdemeanor
			 related to a crime or violation of Title XVIII, XIX, or XX of the Social
			 Security Act or related state laws (or entered a plea of nolo contendere);
(b) Is convicted of fraud related
			 to any federal, state, or locally financed health care program;
(c) Is convicted of interference with the
			 investigation of health care fraud;
(d) Is convicted of unlawfully manufacturing,
			 distributing, prescribing, or dispensing a controlled substance;
(e) Fails to comply with the state and
			 federal statutory requirements set forth in OAR
			 333-010-0275;
(f) By actions of any state
			 licensing authority for reasons relating to the provider's professional
			 competence, professional conduct, or financial integrity:
(A) Has a health care license suspended or
			 revoked, or has otherwise lost such license; or
(B) Surrenders a health care license during a
			 pending formal disciplinary proceeding;
(g) Is suspended or excluded from
			 participation in a federal or state health care program for reasons related to
			 professional competence, professional performance, or other reason;
(h) Engages in improper billing practices,
			 including:
(A) Billing for excessive charges
			 or visits;
(B) Submitting a false
			 claim for payment;
(C) Altering a
			 claim in such a way as to result in a payment for a service that has already
			 been paid; or
(D) Making a claim
			 upon which payment has been made by another source unless the amount paid is
			 clearly entered on the claim form;
(i) Fails to furnish services as required by
			 law or contract with the Center, if the failure has adversely affected (or has
			 a substantial likelihood of adversely affecting) the client;
(j) Fails to supply requested information on
			 subcontractors and suppliers of goods or services;
(k) Fails to supply requested payment
			 information;
(l) Fails to grant
			 access to facilities or provide records upon request of the Center or a
			 designated requestor;
(m) Receives
			 payments for services provided to persons who were not eligible;
(n) Establishes multiple claims using
			 procedure codes that overstate or misrepresent the level, amount or type of
			 health care provided;
(o) Fails to
			 develop, maintain, and retain, in accordance with relevant rules and standards
			 adequate clinical or other records that document the medical appropriateness,
			 nature, and extent of the health care provided;
(p) Fails to develop, maintain, and retain,
			 in accordance with relevant rules and standards, adequate financial records
			 that document charges incurred by a client and payments received from any
			 source;
(q) Fails to follow
			 generally accepted accounting principles or accounting standards or cost
			 principles required by federal or state laws, rules, or regulation;
(r) Submits claims for services provided that
			 were contrary to generally accepted standards of medical practice;
(s) Submits claims for services that exceed
			 that requested or agreed to by the client or the responsible relative or
			 guardian or requested by another medical practitioner;
(t) Breaches the terms of the medical
			 services agreement;
(u) Fails to
			 correct deficiencies in operations after receiving written notice of the
			 deficiencies from the Center;
(v)
			 Fails to submit a billing error edit correction within 30 days of receipt of
			 the third party payment or to refund the appropriate amount within this time
			 frame;
(w) Provides or bills for
			 services provided by ineligible or unsupervised staff;
(x) Submits claims for payment, either
			 personally or through claims submitted by any billing provider or other
			 provider, for any services or supplies provided under the WW Program for
			 services provided after being suspended or terminated from participation in a
			 federal or state medical program, such as Medicare or Medicaid, or after his or
			 her license to practice has been suspended or revoked by a state licensing
			 board;
(y) Fails to notify the
			 Center of a change of TIN within 30 days; or
(z) Fails to respond to a request for records
			 under OAR
			 333-010-0270.