6 Pa. Code § 22.84 - Administrative actions and penalties
(a)
Grounds for action. The
Department may terminate an enrolled provider 's agreement and seek restitution
from that provider if it determines that the provider, owner of the provider,
an employe of the provider or an agent of the provider has done one of the
following:
(1) Failed to comply with §
22.82 (relating to false or
fraudulent claims by providers) or other provisions of the PACE
Program.
(2) Failed to comply with
the conditions of participation in the PACE Program.
(3) Failed to comply with the terms of the
provider agreement.
(4) Been
precluded or excluded for cause, either voluntarily or involuntarily, from
Medicare or Medical Assistance.
(5)
Been convicted of a Medicare or Medical Assistance related criminal offense as
certified by a Federal, State or local court.
(6) Been convicted of a criminal offense
under State or Federal laws relating to the practice of the provider's
profession as certified by a court.
(7) Been subject to license suspension or
revocation following disciplinary action entered against the provider by the
State licensing or certifying agency.
(8) Had a controlled drug license withdrawn
or failed to report to the Department changes in the provider's Drug
Enforcement Agency Number.
(9) In
the case of dispensing physicians who are providers, dispensed prescriptions
which the Department has determined to be harmful to the claimant , of inferior
quality or medically unnecessary.
(10) Refused to permit authorized State or
Federal officials or their agents to examine the provider's medical, fiscal or
other records as necessary to verify claims under the PACE Program.
(b)
Procedures for
terminating provider agreements.
(1)
The Department , upon notice, may terminate the agreement of, and suspend
payments to, an enrolled provider .
(2) Termination for criminal conviction or
administrative action will be as follows:
(i)
The Department will terminate an enrolled provider 's agreement for a period of
up to 5 years if the provider is convicted of a Medicare /Medical Assistance
related crime or a criminal offense under State or Federal law relating to the
practice of the provider's profession. If the Department has an additional
basis for termination which is unrelated to the criminal conviction, it may
terminate the provider agreement for a period in excess of 5 years.
(ii) If the additional basis for the
termination is a license suspension or revocation following disciplinary action
entered against the provider by the State licensing or certifying agency, the
period of termination will be the duration of the disciplinary action plus 5
years for the criminal conviction.
(iii) If the Department has a basis for
termination which is related to the criminal conviction, with the exception of
exclusions from Medicare or Medical Assistance, the minimum period of the
termination will be the longer of 5 years or the period related to the other
action.
(c)
Effects of termination on providers.
(1) The Department will not pay providers for
prescription drugs dispensed on or after the effective date of the termination
of a provider agreement.
(2) An
enrolled provider whose agreement has been terminated may not receive payments
from the PACE Program during the period of termination.
(3) If a provider appeals the Department 's
action of terminating the provider agreement, the Department will not pay the
provider for prescription drugs dispensed on or after the effective date
specified in the notice of termination.
(d)
Notification of termination of a
provider agreement.
(1) The
Department will issue a notice of termination to an enrolled provider whose
agreement is being terminated for cause or as a result of a criminal
conviction.
(2) The notice will
state the basis for the action, the effective date, whether the Department will
consider re-enrollment and, if so, the date when re-enrollment will be
considered.
(e)
Dissemination of information.
(1) When the Department takes action against
a provider, including termination and initiation of a civil suit, it may also
notify and give the reason for the termination to the following:
(i) The Medicaid Fraud Control Unit , Office
of the Attorney General.
(ii) The
Health Care Financing Administration.
(iii) Other State and local agencies involved
in providing or paying for the provision of health care.
(iv) The applicable Commonwealth professional
licensing board.
(v) The United
States Postal Service.
(2) After final adjudication, a copy of the
notice of termination and the reasons for termination may be made available to
Medicaid agencies of other states, the appropriate professional associations
and the news media. Detailed case material and findings will be made available
to the agencies specified in paragraph (1) if the agencies are
notified.
(f)
Referral of criminal offenders. In the case of a provider
which the Department determines has criminally violated any of the provisions
of the PACE Program, the Department may refer the provider to the proper
authorities for prosecution under the act or other applicable laws.
(g)
Restitution and
repayment.
(1) If the Department
determines that a provider has billed and received payment for prescription
drugs 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 may conduct a test audit and base the
restitution amount on the findings of that audit or any extrapolations from
those findings.
(2) The amount of
restitution or repayment shall be equal to the amount of all unauthorized
payments which the Department has made to a provider plus interest.
(3) In the case of unauthorized payments made
as a result of criminal action on the part of a provider, the provider shall,
if found guilty under the act , be subject to repay three times the value of the
material gain received.
(4) 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 .
(5) If the Department determines that a
provider has committed a prohibited act or has failed to satisfy any
requirement under §
22.82, it may institute a civil action against the
provider in addition to terminating the provider's enrollment.
(6) The provider is prohibited from billing a
claimant for any amount for which the provider is required to make restitution
to the Department .
(h)
Suspension of payments. If the Department determines that a
provider has submitted a claim for payment which violates the PACE Program, the
provider may be notified in writing that payment on outstanding invoices will
be delayed or suspended for a period not to exceed 120 days pending a review of
his billing and service patterns. In this situation, the Department reserves
the right to waive the 21 day payment provision of §
22.11 (relating to general payment
principles).
Notes
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