Oregon Administrative Rules › Chapter 333 - OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION › Division 10 - HEALTH PROMOTION AND CHRONIC DISEASE PREVENTION › Section 333-010-0180 - Provider Sanctions

Current through Register Vol. 63, No. 7, July 1, 2024
The following are conditions that may result in the imposition
				of a sanction on a provider.
(1) Basis
			 for Sanction:
(a) Conviction of a provider 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) Conviction of
			 fraud related to any federal, state, or locally financed health care program;
(c) Conviction of interference
			 with the investigation of health care fraud;
(d) Conviction of unlawfully manufacturing,
			 distributing, prescribing, or dispensing a controlled substance;
(e) Failure to comply with the state and
			 federal statutory requirements set forth in OAR 333-010-0165;
(f) By actions of any state licensing
			 authority for reasons relating to the provider's professional competence,
			 professional conduct, or financial integrity, the provider either:
(A) Had a health care license suspended or
			 revoked, or has otherwise lost such license; or
(B) Surrendered the license while a formal
			 disciplinary proceeding was pending before a licensing authority.
(g) Suspension or exclusion from
			 participation in a federal or state health care program for reasons related to
			 professional competence, professional performance, or other reason;
(h) Improper billing practices, including
			 billing for excessive charges or visits;
(i) Failure 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) Failure to supply requested information
			 on subcontractors and suppliers of goods or services;
(k) Failure to supply requested payment
			 information;
(l) Failure to grant
			 access to facilities or provide records upon request of the Center or a
			 designated Requestor;
(m) Receiving
			 payments for services provided to persons who were not eligible;
(n) Establishing multiple claims using
			 procedure codes that overstate or misrepresent the level, amount or type of
			 health care provided;
(o) Failure
			 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) Failure 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) Failure to follow
			 generally accepted accounting principles or accounting standards or cost
			 principles required by federal or state laws, rule, or regulation;
(r) Submission of claims or written orders
			 contrary to generally accepted standards of medical practice;
(s) Submission of 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) Breach of the terms of the medical
			 services agreement;
(u) Failure to
			 correct deficiencies in operations after receiving written notice of the
			 deficiencies from the Center;
(v)
			 Submission of any claim for payment for which payment has already been made by
			 the Center; or
(w) Provision of or
			 billing for services provided by ineligible or unsupervised staff.