Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.75 - Provider prohibited acts

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
				  enrolled provider may not, either directly or indirectly, do any of the
				  following acts:
(1) Knowingly or
				  intentionally present for allowance or payment a false or fraudulent claim or
				  cost report for furnishing services or merchandise under MA, knowingly present
				  for allowance or payment a claim or cost report for medically unnecessary
				  services or merchandise under MA, or knowingly submit false information, for
				  the purpose of obtaining greater compensation than that to which the provider
				  is legally entitled for furnishing services or merchandise under MA.
(2) Knowingly submit false information to
				  obtain authorization to furnish services or items under MA.
(3) Solicit, receive, offer or pay a
				  remuneration, including a kickback, bribe or rebate, directly or indirectly, in
				  cash or in kind, from or to a person in connection with furnishing of services
				  or items or referral of a recipient for services and items.
(4) Submit a duplicate claim for services or
				  items for which the provider has already received or claimed reimbursement from
				  a source.
(5) Submit a claim for
				  services or items which were not rendered by the provider or were not rendered
				  to a recipient.
(6) Submit a claim
				  for services or items which includes costs or charges which are not related to
				  the cost of the services or items.
(7) Submit a claim or refer a recipient to
				  another provider by referral, order or prescription, for services, supplies or
				  equipment which are not documented in the record in the prescribed manner and
				  are of little or no benefit to the recipient, are below the accepted medical
				  treatment standards, or are not medically necessary.
(8) Submit a claim which misrepresents the
				  description of the services, supplies or equipment dispensed or provided, the
				  date of service, the identity of the recipient or of the attending,
				  prescribing, referring or actual provider.
(9) Submit a claim for a service or item at a
				  fee that is greater than the provider's charge to the general public.
(10) Except in emergency situations,
				  dispense, render or provide a service or item without a practitioner's written
				  order and the consent of the recipient or submit a claim for a service or item
				  which was dispensed or provided without the consent of the recipient.
(11) Except in emergency situations,
				  dispense, render or provide a service or item to a patient claiming to be a
				  recipient without first making a reasonable effort to verify by a current
				  Medical Services Eligibility card that the patient is an eligible recipient
				  with no other medical resources.
(12) Enter into an agreement, combination or
				  conspiracy to obtain or aid another in obtaining payment from the Department
				  for which the provider or other person is not entitled, that is,
				  eligible.
(13) Make a false
				  statement in the application for enrollment or reenrollment in the
				  program.
(14) Commit a prohibited
				  act specified in §
											1102.81(a)
				  (relating to prohibited acts of a shared health facility and providers
				  practicing in the shared health facility).