(a) If
the Department determines that a provider has billed and been paid for a
service or item for which payment should not have been made, it will review the
provider's paid and unpaid invoices and compute the amount of the overpayment
or improper payment. The Department will use statistical sampling methods and,
where appropriate, purchase invoices and other records for the purpose of
calculating the amount of restitution due for a service, item, product or drug
substitution.
(b) The Department may
seek reimbursement from the ordering or prescribing provider for payments to
another provider, if the Department determines that the ordering or prescribing
provider has done either of the following:
(1) Prescribed excessive diagnostic services;
or
(2) Ordered diagnostic services
or treatment or both, without documenting the medical necessity for the service
or treatment in the medical record of the MA recipient.
(c) The amount of restitution demanded by the
Department will be the amount of the overpayment received by the ordering or
prescribing provider or the amount of payments to other providers for excessive
or unnecessary services prescribed or ordered. If the ordering or prescribing
provider is convicted of an offense under Article XIV of the Public Welfare
Code (62 P. S. §§
1401-1411), the restitution
penalties of that article applies.
(d) The provider shall pay the amount of
restitution owed to the Department either directly or by offset of valid
invoices that have not yet been paid. The method of repayment is determined by
the Department. All Departmental demands for restitution will be approved by
the Deputy Secretary for Medical Assistance before the provider is
notified.
(e) If the Department
determines that a provider has committed any prohibited act or has failed to
satisfy any requirement under §
1101.75(a)
(relating to provider prohibited acts), it may institute a civil action against
the provider in addition to terminating the provider's enrollment. If the
Department institutes a civil action against the provider, the Department may
seek to recover twice the amount of excess benefits or payments plus legal
interest from the date the violations occurred.
(f) The provider is prohibited from billing
an eligible recipient for any amount for which the provider is required to make
restitution to the Department.
