Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.589 - Scope of Sanction

Current through Reg. 49, No. 28; July 12, 2024
(a) A sanction may
				  be applied to all affiliates of a provider after considering all relevant facts
				  and circumstances. The violation, failure, or inadequacy of performance may be
				  attributed to a provider's affiliate if the affiliate knew or approved of the
				  misconduct within the course of his official duty.
(b) When a person is excluded under the
				  provisions of § 79.2105 of this title (relating to Grounds for Fraud
				  Referral and Administrative Sanction) he must neither personally nor through a
				  clinic, group, corporation, or other association bill or receive payment for
				  any Title XIX or XX services or supplies provided on or after the date of the
				  exclusion. Additionally, he must not order or prescribe services to Title XIX
				  or XX recipients after that date. A clinic, group, corporation, or other
				  association that is a provider is not permitted to submit claims for any
				  services or supplies provided by a person within the organization who is
				  excluded from participation unless the services or supplies are provided before
				  the exclusion effective date. A provider is not permitted to include in a cost
				  report or any documents used to determine an individual payment rate, a
				  statewide payment rate, or a fee, the salary, fringe, overhead, or any other
				  costs associated with any employee, owner, officer, director, board member,
				  independent contractor, or agent associated with the provider who was
				  previously excluded from the Medicare or Medicaid Program for program abuse.
				  Under certain circumstances, depending upon the reason for exclusion, the
				  department does not permit the excluded physician or individual to act as a
				  stockholder owning 5.0% or more ownership interest, officer, director, board
				  member, independent contractor, manager, consultant, employee providing or
				  billing for services provided to Title XIX or XX recipients, or agent
				  associated with a Title XIX or XX provider. Additionally, the department may
				  exclude a Title XIX or XX provider who knowingly and willingly uses a person or
				  entity as an employee, independent contractor, or agent who was previously
				  excluded under these provisions.
(c) If any of the sections in this subchapter
				  and in §§ 79.2301-79.2305 of this title (relating to Recovery of
				  Benefits Wrongfully Received); state or federal law; provider agreements,
				  provider manuals, or Medicaid bulletins are violated, the department may
				  exclude the organization and any person in the organization who is responsible
				  for the violation.
(d) To be
				  readmitted, the provider must reapply for participation after exclusion. The
				  department or its agent considers the merits of the case.
(e) Except as specified in subsection (f) of
				  this section, no Title XIX or XX payments are made for services or supplies
				  provided by participating provider that have been prescribed or ordered by an
				  excluded practitioner on or after the effective date specified by the
				  department. This date is subsequent to the actual effective date of the
				  provider exclusion unless the provider's license to practice has been
				  cancelled, in which case nothing can be ordered or prescribed after license
				  cancellation. The following criteria are used to determine when payments begin
				  to be denied.
(1) If the department excludes
				  under its own authority and the excluded provider fails to appeal, payments are
				  denied 45 days from the date the excluded provider's right to appeal
				  expires.
(2) If the department
				  excludes under its own authority and the excluded provider appeals within the
				  time allowed, payments are denied 45 days from the date of the administrative
				  law judge's final decision.
(3) If
				  the department excludes under a mandate by the Department of Health and Human
				  Services, and Federal Financial Participation (FFP) is denied, payments are
				  denied 45 days from the date of exclusion. When FFP is denied, the state
				  statute postponing the exclusion until after disposition of the appeal does not
				  apply.