Iowa Admin. Code r. 441-152.10 - Sanctions against providers
Failure to meet the requirements relevant to
(1)
Grounds for sanction.
The department may impose sanctions against a provider for committing one or
more of the following actions:
a. Failing to
provide and maintain the quality of the services to children and families
within established standards, including:
(1)
Failing to meet standards required by state or federal law for
licensure.
(2) Failing to correct
deficiencies in provider operations after receiving notice of these
deficiencies from the department .
(3) Engaging in a course of conduct or
performing an act that is in violation of state or federal regulations or
continuing that conduct following notification that it should cease.
(4) Violating any laws, regulations, or code
of ethics governing the conduct of occupations or professions subject to this
chapter
(5) Receiving a formal
reprimand or censure by an association of the provider 's peers for unethical
practices.
(6) Being suspended or
terminated from participation in another governmental program such as, but not
limited to, workers' compensation or Medicaid remedial services.
(7) Committing a negligent practice resulting
in client death or injury.
b. Failing to disclose or make available to
the department or its authorized agent records of services provided to a child
and family and records of payments made for those services.
c. Engaging in deceptive billing practices,
such as:
(1) Presenting or causing to be
presented for payment any false or deceptive claim for services.
(2) Submitting or causing to be submitted
false information for the purpose of obtaining greater compensation than that
to which the provider is legally entitled.
d. Submitting or causing to be submitted
false information to meet service authorization requirements.
e. Inducing, furnishing or otherwise causing
the child or family to receive foster group care services that are not
authorized (overutilization of services).
f. Rebating or accepting a fee or portion of
a fee or a charge for referrals of a child or family.
g. Failing to repay or arrange for the
repayment of identified overpayments or other erroneous payments.
(2)
Notice of
violation. Should the department have information that indicates that
a provider may have submitted bills or been practicing in a manner inconsistent
with the program requirements, or may have received payment for which the
provider may not be properly entitled, the department shall notify the provider
of the discrepancies noted.
a. Notification
shall set forth:
(1) The nature of the
discrepancies or violations.
(2)
The known dollar value of the discrepancies or violations.
(3) The method of computing the dollar
value.
(4) Further actions to be
taken or sanctions to be imposed by the department .
(5) Any actions required of the
provider
b. The provider
shall have 15 days after the date of the notice and before the department
action to show cause why the action should not be taken.
(3)
Sanctions. The following
sanctions may be imposed on providers based on the grounds specified in subrule
152.10(1):
a. A term of probation for
provision of foster group care services.
b. Termination from participation in the
provision of foster group care services.
c. Suspension from provision of foster group
care services.
d. Suspension or
withholding of payments to the provider
e. Review of 100 percent of the provider 's
claims before payment.
f. Referral
to the appropriate state licensing board for investigation.
g. Referral of the matter to appropriate
federal or state legal authorities for investigation and prosecution under
applicable federal or state laws.
h. Suspension of foster group care services
licensure.
z. Termination of
foster group care services licensure.
(4)
Imposition and extent of
sanction. The department shall determine what sanction to impose. The
following factors shall be considered in determining the sanction or sanctions
to be imposed:
a. Seriousness of the
offense.
b. Extent of
violations.
c. History of prior
violations.
d. Prior imposition of
sanctions.
e. Prior provision of
technical assistance.
f. Pattern of
failure to follow program rules.
g.
Whether a lesser sanction will be sufficient to remedy the problem.
h. Actions taken or recommended by peer
review groups or licensing bodies.
(5)
Scope of sanction.
a. The sanction may be applied to all known
affiliates of a provider Each decision to include an affiliate shall be made on
a case-by-case basis after giving due regard to all relevant factors and
circumstances. The violation, failure, or inadequacy of performance may be
imputed to a person with whom the violator is affiliated when the conduct was
committed in the course of official duty or was effectuated with the knowledge
or approval of that person.
b. When
there are grounds for sanction pursuant to subrule 152.10(1) against a provider
facility, campus, or site , the department may suspend or terminate the
provision of foster group care services by:
(1) The provider ; or
(2) The specific facility, campus, or site ;
or
(3) Any individual within the
provider 's organization who is responsible for the violation.
c. No provider shall submit claims
for payments to the department for any services provided by any facility,
campus, site , or person within the organization that has been suspended or
terminated from provision of foster group care services except for those
services provided before the suspension or termination.
d. Suspension or termination from provision
of foster group care services shall preclude the submission of claims to the
department for payment for any services provided after suspension or
termination, whether submitted personally or through the provider .
(6)
Suspension or
withholding of payments pending a final determination. When the
department has notified a provider of a violation pursuant to paragraph
152.9(5)"b " or subrule 152.10(2) and has demanded repayment
of an identified overpayment , the department may withhold payments on pending
and subsequently received claims in an amount reasonably calculated to
approximate the amounts in question or may suspend payment pending a final
determination. When the department intends to withhold or suspend payments, it
shall notify the provider in writing.
(7)
Notice of sanction. When
a provider has been sanctioned, the department shall notify, as appropriate,
the applicable professional society, board of registration or licensure, and
federal or state agencies of the findings made and the sanctions
imposed.
Notes
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