Wis. Admin. Code Department of Health Services DHS 106.08 - Intermediate sanctions

(1) To enforce compliance with MA program requirements, the department may impose on a provider for a violation listed under sub. (2) one or more of the sanctions under sub. (3) unless the requirements of s. DHS 106.065 apply. Any sanction imposed by the department pursuant to this section may be appealed by the provider under s. DHS 106.12. Prior to imposing any alternative sanction under this section the department shall issue a written notice to the provider in accordance with s. DHS 106.12(3). Nothing in this chapter shall be construed to compel the department, through a fair hearing or otherwise, to impose an intermediate sanction in lieu of suspension or termination of certification, a different intermediate sanction, monetary recoveries, auditing, withholding of claims or pre-payment review, nor may imposition of an intermediate sanction on a provider be construed to limit the department's authority under s. DHS 106.06, 106.065, 106.07, 106.10 or 106.11, under this section, or under the applicable provider agreement, concluded pursuant to s. 49.45(2) (a) 9, Stats.

(2) The department may impose an intermediate sanction under sub. (3) for any of the following violations of this chapter:

(a) For conduct specified in s. DHS 106.06;

(b) For refusal to grant the department access to records under s. DHS 106.02(9) (e);

(c) For conduct resulting in repeated recoveries under s. DHS 108.02(9);

(d) For non-compliance with one or more certification requirement applicable to the type of provider under ch. DHS 105;

(e) For interference with recipient rights specified under ch. DHS 104; or

(f) For refusal or repeated failure to comply with one or more requirement specified under this chapter.

(3) The department may impose one or more of the following intermediate sanctions for a violation listed under sub. (2):

(a) Referral to the appropriate peer review organization, licensing authority or accreditation organization;

(b) Transfer to a provider agreement of limited duration which also may stipulate specific conditions of participation;

(c) Requiring prior authorization of some or all of the provider's services;

(d) Review of the provider's claims before payment;

(e) Restricting the provider's participation in the MA program;

(f) Requiring an independent audit of the provider's practices and records, with the findings and recommendations to be provided to the department;

(g) Requiring the provider to perform a self-audit following instructions provided by the department; and

(h) Requiring the provider, in a manner and time specified by the department, to correct deficiencies identified in a department audit, independent audit or department survey or inspection.

(4) In determining the appropriate sanction or sanctions to be applied to a non-compliant provider and the duration of the sanction or sanctions, the department shall consider:

(a) The seriousness and extent of the offense or offenses;

(b) History of prior offenses;

(c) Prior sanctions;

(d) Provider willingness and ability to comply with MA program requirements;

(e) Whether a lesser sanction will be sufficient to remedy the problem in a timely manner;

(f) Actions taken or recommended by peer review organizations, licensing authorities and accreditation organizations;

(g) Potential jeopardy to recipient health and safety and the relationship of the offense to patient care; and

(h) Potential jeopardy to the rights of recipients under federal or state statutes or regulations.

Notes

Wis. Admin. Code Department of Health Services DHS 106.08

Cr. Register, February, 1993, No. 446, eff. 3-1-93; corrections in (2) (c), (d) and (e) made under s. 13.92(4) (b) 7, Stats., Register December 2008 No. 636.