Or. Admin. R. 333-010-0180 - Provider Sanctions

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.
(2) A provider who has been suspended or terminated from participation in a federal or state medical program, such as Medicare or Medicaid, or whose license to practice has been suspended or revoked by a state licensing board, shall not submit claims for payment, either personally or through claims submitted by any billing provider or other provider, for any services or supplies provided under ScreenWise BCC, except those services provided prior to the date of suspension or termination.
(3) When the provisions of section (2) of this section are violated, the Center may suspend or terminate the provider who is responsible for the violation.
(4) Provider sanctions will be imposed at the discretion of the Authority or the administrator of the office whose budget includes payment for the services involved.

Notes

Or. Admin. R. 333-010-0180
PH 9-2008, f. & cert. ef. 6-16-08; PH 11-2016, f. & cert. ef. 4/1/2016

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042

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