N.D. Admin Code 75-02-05-05 - Grounds for sanctioning providers

Current through Supplement No. 383, January, 2022

Sanctions may be imposed by the department against a provider who:

1. Presents or causes to be presented for payment any false or fraudulent claim for care or services.
2. Submits or causes to be submitted false, intentionally misleading, or fraudulent information for the purpose of obtaining greater compensation than that to which the provider is legally entitled.
3. Submits or causes to be submitted false, intentionally misleading, or fraudulent information for the purpose of meeting prior authorization or level of care requirements.
4. Submits or causes to be submitted false, intentionally misleading, or fraudulent information in an application status for provider status under the Medicaid or children's health insurance program or any quality review or other submission required to maintain enrollment.
5. Fails to disclose or make available to the department or its authorized agent records of services provided to Medicaid and children's health insurance program recipients and records of payments received for those services; or fails to make available records from the provider's practice that allows department staff to evaluate overall scheduling, patient-to-provider ratios, review billing practices, or evaluate the feasibility of services provided per day.
6. Submits a false, intentionally misleading, or fraudulent certification or statement, whether the certification or statement is explicit or implied, to the department or department's representative or to any other publicly or privately funded health care program.
7. Fails to provide and maintain services to Medicaid and children's health insurance program recipients within accepted medical and industry standards. Failing to provide or maintain quality services, or a requisite assurance of a framework of quality services to Medicaid and children's health insurance program recipients within accepted medical community standards as adjudged by professional peers, if applicable. For purposes of this subsection, "quality services" mean services provided in accordance with the applicable rules and regulations governing the services.
8. Fails to comply with the terms of the Medicaid provider agreement or provider certification which is printed on the Medicaid claim form.
9. Overutilizes the Medicaid and children's health insurance program by inducing, furnishing, or otherwise causing a recipient to receive care and services that are not medically necessary.
10. Rebates or accepts a fee or portion of a fee or charge for a Medicaid and children's health insurance program patient referral.
11. Is convicted of a criminal offense arising out of the practice of medicine.
12. Fails to comply and to maintain compliance with all regulations and statutes, both state and federal, which are applicable to the provider's profession, business, or enterprise.
13. Is excluded from Medicare.
14. Is suspended, excluded from participation, terminated, or sanctioned by any other state's Medicaid and children's health insurance program.
15. Is suspended or involuntarily terminated from participation in any governmentally sponsored medical program.
16. Bills or collects from the recipient any amount in violation of section 75-02-05-04.
17. Fails to correct deficient provider operations within a reasonable time, not to exceed thirty days, after receiving written notice of these deficiencies from the department, another responsible state agency, or their designees.
18. Is formally reprimanded or censured by an association of the provider's peers for unethical practices.
19. Fails to change or modify delivery patterns and services within a reasonable period after receipt of a request so to do by a peer review committee whose jurisdiction includes the provider.
20. Is convicted of a criminal offense arising out of the making of false or fraudulent statements or of an omission of fact for the purpose of securing any governmental benefit to which the provider is not entitled, or out of conspiring, soliciting, or attempting such an action.
21. Refuses to repay or make arrangements for the repayment of identified overpayments or otherwise erroneous payments. A refusal of repayment exists if no repayment or arrangement for repayment is made within thirty days of the date written notice of discrepancy was sent.
22. Is served with a search warrant by a member of any law enforcement agency for the purpose of obtaining evidence of a crime of fraud committed by that provider against the Medicaid or children's health insurance program, or is charged with such a crime, provided that no provider may be terminated from participation in the Medicaid or children's health insurance program on such grounds.
23. Refuses to attend a department educational program or fails to agree to implement a business integrity agreement, if required by the department.
24. Defrauds any health care benefit program.

Notes

N.D. Admin Code 75-02-05-05
Amended by Administrative Rules Supplement 2014-352, April 2014, effective April 1, 2014. . Amended by Administrative Rules Supplement 368, April 2018, effective April 1, 2018.

General Authority: NDCC 50-06-1.9, 50-24.1-04, 50-29-02

Law Implemented: NDCC 12.1-11-02; 42 CFR 455.13, 42 CFR 455.16, 42 CFR 431.107

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