6 Pa. Code § 22.82 - False or fraudulent claims by providers
An enrolled provider submits a false or fraudulent claim if the provider directly or indirectly commits one or more of the following acts:
(1) Submits false information
for the purpose of obtaining greater compensation than that to which the
provider is legally entitled for dispensing prescription drugs under
PACE.
(2) Submits a claim for
dispensing only part of a prescription amount which is less than the maximum
limit of the program except when the provider can document that insufficient
inventory prevented the dispensing of the program limit and that no additional
dispensing fee or copayments were charged for dispensing the remainder of the
prescription at a later time.
(3)
Submits false information to obtain authorization to dispense prescription
drugs under PACE.
(4) Solicits,
receives, offers or pays remuneration, including a kickback, bribe or rebate,
directly or indirectly in cash or in kind, from or to a person in connection
with the dispensing of prescription drugs or referral of claimants for
prescription drugs.
(5) Submits a
duplicate claim for prescription drugs for which the provider has already
received or claimed reimbursement from any source.
(6) Submits a claim for prescription drugs
which were not dispensed by the provider at the provider's principal place of
business or were not dispensed to a claimant.
(7) Submits a claim for prescription drugs
dispensed which are not documented in the prescribed manner. See 49 Pa. Code
Chapters 16-18 (relating to State Board of Medicine-general provisions; State
Board of Medicine-medical doctors; and State Board of Medicine-practitioners
other than doctors) and 49 Pa. Code §27.78 (relating to standards of
practice).
(8) Submits a claim,
order or prescription, for prescription drugs which are of little or no benefit
to the claimant, are below accepted treatment standards or are not medically
necessary, in the case of a dispensing physician who is a provider.
(9) Submits a claim which misrepresents the
description of the prescription drugs dispensed, the date of service, the
identity of the claimant, the identity of the prescriber or the identity of the
actual provider.
(10) Submits a
claim for a prescription drug dispensed under PACE at a cost that is greater
than the provider's usual charge to the general public.
(11) Submits a claim for a prescription drug
dispensed for which the provider has not collected from the claimant all due
payments, including the required copayment and any applicable generic
differential.
(12) Enters into an
agreement, combination or conspiracy to obtain or aid another in obtaining from
the Department payment to which the provider or other person is not
entitled.
(13) Submits a claim for
prescription drugs dispensed to a claimant outside this Commonwealth.
Notes
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