Pennsylvania Code › Title 6 - AGING › Part I - Department of Aging › Chapter 22 - PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY › PROVIDER MISUTILIZATION AND ABUSE › Section 22.82 - False or fraudulent claims by providers

Current through Register Vol. 54, No. 28, July 13, 2024
An enrolled provider submits a false or fraudulent claim if
					 the provider directly or indirectly commits one or more of the following
					 acts:
(1) Submits false information
				  for the purpose of obtaining greater compensation than that to which the
				  provider is legally entitled for dispensing prescription drugs under
				  PACE.
(2) Submits a claim for
				  dispensing only part of a prescription amount which is less than the maximum
				  limit of the program except when the provider can document that insufficient
				  inventory prevented the dispensing of the program limit and that no additional
				  dispensing fee or copayments were charged for dispensing the remainder of the
				  prescription at a later time.
(3)
				  Submits false information to obtain authorization to dispense prescription
				  drugs under PACE.
(4) Solicits,
				  receives, offers or pays remuneration, including a kickback, bribe or rebate,
				  directly or indirectly in cash or in kind, from or to a person in connection
				  with the dispensing of prescription drugs or referral of claimants for
				  prescription drugs.
(5) Submits a
				  duplicate claim for prescription drugs for which the provider has already
				  received or claimed reimbursement from any source.
(6) Submits a claim for prescription drugs
				  which were not dispensed by the provider at the provider's principal place of
				  business or were not dispensed to a claimant.
(7) Submits a claim for prescription drugs
				  dispensed which are not documented in the prescribed manner. See 49 Pa. Code
				  Chapters 16-18 (relating to State Board of Medicine-general provisions; State
				  Board of Medicine-medical doctors; and State Board of Medicine-practitioners
				  other than doctors) and 49 Pa. Code §
										27.78 (relating to standards of
				  practice).
(8) Submits a claim,
				  order or prescription, for prescription drugs which are of little or no benefit
				  to the claimant, are below accepted treatment standards or are not medically
				  necessary, in the case of a dispensing physician who is a provider.
(9) Submits a claim which misrepresents the
				  description of the prescription drugs dispensed, the date of service, the
				  identity of the claimant, the identity of the prescriber or the identity of the
				  actual provider.
(10) Submits a
				  claim for a prescription drug dispensed under PACE at a cost that is greater
				  than the provider's usual charge to the general public.
(11) Submits a claim for a prescription drug
				  dispensed for which the provider has not collected from the claimant all due
				  payments, including the required copayment and any applicable generic
				  differential.
(12) Enters into an
				  agreement, combination or conspiracy to obtain or aid another in obtaining from
				  the Department payment to which the provider or other person is not
				  entitled.
(13) Submits a claim for
				  prescription drugs dispensed to a claimant outside this Commonwealth.
This section cited in 6 Pa. Code §
												22.62 (relating to conditions of
						provider participation); and 6 Pa. Code §
												22.84 (relating to administrative
						actions and penalties).