Or. Admin. R. 410-170-0120 - Compliance Reviews and Sanctions

(1) The BRS contractor shall cooperate and ensure its BRS providers cooperate with program compliance reviews or audits conducted by any federal or state or local governmental agency or entity related to the BRS program.
(2) The Authority or agency or both shall conduct compliance reviews periodically, including but not limited to review of documentation and onsite inspections.
(3) If the Authority determines that the BRS contractor is not in compliance with its contract to provide BRS services or placement-related activities, including but not limited to non-compliance with state or federal law or regulation, then the Authority may:
(a) Provide technical assistance;
(b) Require the BRS contractor working with its BRS provider to develop and implement a corrective action plan;
(c) Pursue any or all remedies authorized under the contract;
(d) Pursue any other remedy authorized by state or federal law; or
(e) Pursue any combination of the above.
(4) If the Authority determines that the BRS contractor or the BRS provider is not in compliance with state or federal law or regulation then in addition to pursuing any contract remedy, the Authority may:
(a) Provide technical assistance;
(b) Require the BRS contractor working with its BRS provider to develop and implement a corrective action plan;
(c) Refer the case to an appropriate licensing or other federal or state or local oversight governmental agency or entity;
(d) Pursue any other remedy authorized by state or federal law; or
(e) Pursue any combination of the above.
(5) In addition to the remedies provided in sections (3) and (4) above, if the Authority determines that the BRS contractor or the BRS provider is not in compliance with state or federal law or regulation related to Medicaid services, then the Authority may:
(a) Impose sanctions pursuant to OAR 410-120-1400 and 410-120-1460;
(b) Recover an overpayment pursuant to OAR 410-120-1397; or
(c) Any combination of the above.
(6) Overpayment:
(a) When an overpayment is identified, the Authority shall notify the BRS contractor or BRS provider in writing. The overpayment amount shall be determined at the Authority's discretion through direct examination of claims, statistical sampling and extrapolation techniques, or other means. Procedures for recovery of funds are as described in OAR 410-120-1397 or by applicable contract language;
(b) When a BRS contractor or BRS provider discovers that they requested and may have received reimbursement not in compliance with all applicable rules, they shall contact the Division's Medicaid Policy Unit and Office of Payment Accuracy and Recovery (OPAR) promptly to report the possible inappropriate payment and discuss how the appropriateness shall be determined as well as programmatic changes and other notifications to be made.
(7) The BRS contractor or the BRS provider may appeal an Authority's notice of action for sanctions or overpayments under the appeal processes specified in the notice and applicable administrative rules for the Authority.

Notes

Or. Admin. R. 410-170-0120
DMAP 63-2013, f. 11-14-13, cert. ef. 1-1-14; DMAP 118-2018, amend filed 12/26/2018, effective 1/1/2019

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065

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