Utah Admin. Code R414-22-4 - Grounds for Sanctioning Providers

(1) The department may impose sanctions against a provider who:

(a) knowingly presents, or causes to be presented to Medicaid, any false or fraudulent claim other than simple billing errors for services or merchandise;

(b) knowingly submits, or causes to be submitted, false information to obtain greater reimbursement than allowed; or

(c) knowingly submits, or causes to be submitted for Medicaid reimbursement, any claims on behalf of a provider who has been terminated or suspended from the Medicaid program, unless the claims for that provider were included for services or supplies provided before the provider's suspension or termination from the Medicaid program;

(d) knowingly submits, or causes to be submitted, false information to meet Medicaid prior authorization requirements;

(e) fails to keep necessary records to substantiate services provided to Medicaid members;

(f) fails to disclose or make available to the department, its authorized agents, or the Medicaid Fraud Control Unit, records or services provided to Medicaid members or records of payments made for those services; or

(g) fails to provide services to Medicaid members in accordance with accepted medical community standards as adjudged by either a body of peers or appropriate state regulatory agencies;

(h) breaches the terms of the Medicaid provider agreement;

(i) fails to comply with the terms of the provider certification on the Medicaid claim form;

(j) overutilizes the Medicaid program by inducing, providing, or otherwise causing a Medicaid member to receive services or merchandise that is not medically necessary;

(k) rebates or accepts a fee or portion of a fee or charge for a Medicaid member referral;

(l) violates Title 26B, Chapter 3, Health Care - Administration and Assistance, or any other applicable rule or regulation;

(m) knowingly submits a false or fraudulent application for Medicaid provider status;

(n) violates any laws or regulations governing the conduct of health care occupations, professions, regulated industries;

(o) is convicted of a criminal offense related to performance as a Medicaid provider;

(p) conducts a negligent practice resulting in death or injury to a patient as determined in a judicial proceeding;

(q) fails to comply with standards required by state or federal laws and regulations for continued participation in the Medicaid program;

(r) conducts a documented practice of charging Medicaid members for Medicaid-covered services that exceed amounts paid by the department, unless there is a written agreement signed by the member that applicable charges will be paid by the member;

(s) refuses to execute a new Medicaid provider agreement if doing so is necessary to ensure compliance with state or federal law or regulations;

(t) fails to correct any deficiencies listed in a Statement of Deficiencies and Plan of Correction, in provider operations within a specific time frame agreed to by the department and the provider, or pursuant to a court or formal administrative hearing decision;

(u) is suspended or terminated from participation in Medicare for failure to comply with the laws and regulation governing that program;

(v) fails to obtain or maintain licenses required by state or federal law to legally provide Medicaid services; or

(w) fails to repay or make arrangements for repayment of any identified Medicaid overpayments or otherwise erroneous payments, as required by the Utah Medicaid State Plan, court order, or formal administrative hearing decision.

(2) The department may sanction a Medicaid provider who has a current suspension.

(3) The Provider Sanction Committee may sanction a provider if the committee finds the provider either engaged in significant misconduct or there is substantial evidence of misconduct that creates a substantial risk of harm to the Medicaid program.

(4) If after review, the Provider Sanction Committee finds there is earlier misconduct outlined in Section R414-22-3 or Section R414-22-4, the committee retains discretionary authority to not renew a provider agreement, to not reinstate a provider agreement, and to not enroll a provider until the provider has completed requirements deemed necessary by the committee.

Notes

Utah Admin. Code R414-22-4

Amended by Utah State Bulletin Number 2020-05, effective 2/4/2020 Amended by Utah State Bulletin Number 2024-03, effective 1/22/2024