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 357.585 - Grounds for Fraud Referral and Administrative Sanction

Current through Reg. 49, No. 28; July 12, 2024
The department may impose sanctions against a provider or a
					 provider's employee who permits, does, or causes any of the following or for
					 any other reason provided by law or duly-issued regulation. This list is not
					 all inclusive:
(1) submitting a false
				  statement or misrepresentation, or omitting pertinent facts when claiming
				  payment under Medicaid or when supplying information used to determine the
				  right to payment under Medicaid;
(2) submitting a false statement,
				  information, or misrepresentation, or omitting pertinent facts to obtain
				  greater compensation than the provider is legally entitled to;
(3) submitting a false statement,
				  information, or misrepresentation, or omitting pertinent facts to meet prior
				  authorization requirements;
(4)
				  failing to disclose or make available upon request to the department or its
				  authorized agents, representatives of the Department of Health and Human
				  Services, or the Attorney General's Medicaid Fraud Control unit any records the
				  provider is required to maintain or any records necessary to verify items or
				  services furnished under Title XVII or Title XX to determine whether payment
				  for those items or services is due or was properly made. This includes
				  providing documentation or allowing examination of records or both. This also
				  includes records of services provided to Medicaid recipients and payments made
				  for those services, including but not limited to, documents related to
				  diagnosis, treatment, service, lab results, and x-rays. Accessible information
				  must include information that is necessary for the agencies specified in this
				  paragraph to perform statutory functions;
(5) failing to provide and maintain quality
				  services to Medicaid recipients within accepted medical community standards or
				  standards required by statute, regulation, or contract;
(6) failing to comply with the terms of the
				  Medicaid contract or provider agreement, assignment agreement, the provider
				  certification on the Medicaid claim form, or regulations published by the
				  department;
(7) furnishing or
				  ordering services to patients (whether or not eligible for benefits) under
				  Title XVIII or a state health care program that substantially exceed the
				  recipient's needs, are not medically necessary, are not provided economically
				  or are of a quality that fails to meet professionally recognized standards of
				  health care;
(8) rebating or
				  accepting a fee or a part of a fee or charge for a Medicaid patient
				  referral;
(9) violating any
				  provision of the Human Resources Code, Chapter 32, or any rule or regulation
				  issued under the Code;
(10)
				  submitting a false statement or misrepresentation or omitting pertinent facts
				  on any application or any documents requested as a prerequisite for Medicaid
				  participation;
(11) failing to meet
				  standards required for licensure or required by state or federal law,
				  department rule, provider agreement, or provider manuals for participation in
				  the Medicaid Program;
(12) charging
				  recipients for allowable services that exceed the amount the department or its
				  agents pay for except when specifically allowed by the department;
(13) refusing to execute or comply with a
				  provider agreement or amendments when requested;
(14) failing to correct deficiencies in
				  provider operations after receiving written notice of them from the department
				  or its authorized agents;
(15)
				  engaging in any negligent practice resulting in death, injury, or substantial
				  probability of death or injury to the provider's patients and to persons who
				  receive or benefit from the provider's services;
(16) pleading guilty or nolo contendere,
				  agreeing to an order of probation without adjudication of guilt under deferred
				  adjudication, or being a defendant in a court judgment or finding of guilt for
				  a violation relating to performance of a provider agreement or program
				  violation of Medicare, the Texas Medicaid Program, or any other state's
				  Medicaid Program;
(17) failing to
				  repay or make arrangements that are satisfactory to the department to repay
				  identified overpayments or other erroneous payments;
(18) failing to abide by applicable statutes
				  regarding handicapped individuals or civil rights;
(19) being terminated, suspended, or excluded
				  from participation in any federal program having an unpaid debt under any
				  federal program, or being otherwise sanctioned under any federal program
				  involving the provision of health care, including the Department of Defense,
				  the Veterans Administration, and any state health care program for actions or
				  failure to act that would be considered abusive or fraudulent. This includes
				  any reasons related to the person's professional competence or performance or
				  financial integrity. Any appeal by the provider for an action taken against him
				  under this item does not consider the validity of a sanction or action taken by
				  Medicare or any other state's Medicaid Program;
(20) submitting or causing to be submitted
				  under Title XVIII or a state health care program claims or requests for payment
				  containing unjustified charges or costs for items or services that
				  substantially exceed the person's usual and customary charges or costs for
				  those items or services to the public or the private pay patients;
(21) failing to comply with Medicaid
				  policies, published Medicaid bulletins, policy notification letters, provider
				  policy or procedure manuals, contracts, statutes, rules, regulations, or
				  previously sent interpretations to the provider of any of the items
				  listed;
(22) submitting claims with
				  a pattern of inappropriate coding or billing that results in excessive costs to
				  the Medicaid Program;
(23) billing
				  for services or merchandise that was not provided to the recipient;
(24) submitting to the Medicaid Program a
				  cost report containing costs not associated with the Medicaid Program or not
				  permitted by Medicaid program policies;
(25) submitting a false statement or
				  misrepresentation that, if used, has the potential of increasing any individual
				  or state provider payment rate or fee;
(26) charging recipients for services when
				  payment for the services was recouped by Medicaid because of any of the reasons
				  stated in § 79.2303 of this title (relating to Recovery From
				  Providers);
(27) failing to notify
				  and reimburse the department or its agents for services paid by Medicaid if the
				  provider also receives reimbursement from a liable third party;
(28) misapplying, misusing, embezzling,
				  failing to promptly release upon a valid request, or failing to keep detailed
				  receipts of expenditures relating to any funds or other property in trust for a
				  Medicaid recipient;
(29) pleading
				  guilty or being convicted of a violation of state or federal statutes relating
				  to dangerous drugs, controlled substances, or any other drug-related
				  offense;
(30) pleading guilty of,
				  being convicted of, or engaging in conduct involving moral turpitude;
(31) having a voluntary or involuntary action
				  taken by a licensing agency or board to require the provider or employee to
				  comply with professional practice requirements of the board after the board
				  receives evidence of noncompliance with licensing requirements;
(32) pleading guilty or being convicted of a
				  violation of state or federal statutes relating to fraud, theft, embezzlement,
				  breach of fiduciary responsibility, or other financial misconduct relating to
				  the delivery of a health care item or service or relating to any act or
				  omission in a program operated or financed by any federal, state, or local
				  government agency;
(33) being
				  convicted in connection with the interference with or obstruction of any
				  investigation into any criminal offense described in §79.2112(f) of this
				  title (relating to Administrative Sanctions or Actions) or paragraphs (16),
				  (29), (30), or (32) of this subsection.
(34) having its license to provide health
				  care revoked or suspended by any state licensing authority, or losing this
				  license because of action based on assessment of the person's professional
				  competence, professional performance, or financial integrity, or surrendering
				  this license while a formal disciplinary proceeding is pending before licensing
				  authorities when the proceeding concerns the person's professional competence,
				  professional performance, or financial integrity;
(35) substantially failing, as a health
				  maintenance organization under Title XIX or any entity furnishing services
				  under waiver granted by the United States Department of Health and Human
				  Services (HHS) under that title, to provide medically necessary items or
				  services that are required under law or under contract, if the failure has
				  adversely affected or is substantially likely to adversely affect the medicaid
				  recipient of these items or services;
(36) substantially failing, as an eligible
				  organization under a risk sharing contract as defined in
				  RSA
				  1395mm, to provide medically necessary items
				  or services that are required under law or contract, if the failure has
				  adversely affected or has the potential to adversely affect the
				  patient;
(37) committing an act
				  described in the Social Security Act, §1128A or §1128B.
(38) meeting any of the conditions specified
				  in §79.2112(f) or (g) of this title (relating to Administrative Sanctions
				  or Actions);
(39) failing to fully
				  and accurately make any disclosure required by the Social Security Act,
				  §1124 or §1126.
(40)
				  failing to disclose information about the ownership of a subcontractor with
				  whom the person has had business transactions in an amount exceeding $25,000
				  during the previous 12 months or about any significant business transactions
				  (as defined by HHS) with any wholly-owned supplier or subcontractor during the
				  previous five years;
(41) failing,
				  as a hospital, to comply substantially with a corrective action required under
				  the Social Security Act, §1886(f)(2)(B);
(42) defaulting on repayments of scholarship
				  obligations or items relating to health profession education made or secured,
				  in whole or in part, by HHS when HHS has taken all reasonable steps available
				  to HHS to secure repayment.
(43)
				  developing false source documents or failing to sign source documents, to
				  retain supporting documentation, or to comply with the provisions or
				  requirements of the department pertaining to electronic claims
				  submittal.