(1)The Center may sanction an enrolling provider if the provider:
(a)Is convicted of a felony or misdemeanor related to a crime or violation of Title XVIII, XIX, or XX of the Social Security Act or related state laws (or entered a plea of nolo contendere);
(b)Is convicted of fraud related to any federal, state, or locally financed health care program;
(c)Is convicted of interference with the investigation of health care fraud;
(d)Is convicted of unlawfully manufacturing, distributing, prescribing, or dispensing a controlled substance;
(e)Fails to comply with the state and federal statutory requirements set forth in OAR 333-010-0275 (Compliance with Federal and State Statutes);
(f)By actions of any state licensing authority for reasons relating to the provider’s professional competence, professional conduct, or financial integrity:
(A)Has a health care license suspended or revoked, or has otherwise lost such license; or
(B)Surrenders a health care license during a pending formal disciplinary proceeding;
(g)Is suspended or excluded from participation in a federal or state health care program for reasons related to professional competence, professional performance, or other reason;
(h)Engages in improper billing practices, including:
(A)Billing for excessive charges or visits;
(B)Submitting a false claim for payment;
(C)Altering a claim in such a way as to result in a payment for a service that has already been paid; or
(D)Making a claim upon which payment has been made by another source unless the amount paid is clearly entered on the claim form;
(i)Fails to furnish services as required by law or contract with the Center, if the failure has adversely affected (or has a substantial likelihood of adversely affecting) the client;
(j)Fails to supply requested information on subcontractors and suppliers of goods or services;
(k)Fails to supply requested payment information;
(l)Fails to grant access to facilities or provide records upon request of the Center or a designated requestor;
(m)Receives payments for services provided to persons who were not eligible;
(n)Establishes multiple claims using procedure codes that overstate or misrepresent the level, amount or type of health care provided;
(o)Fails to develop, maintain, and retain, in accordance with relevant rules and standards adequate clinical or other records that document the medical appropriateness, nature, and extent of the health care provided;
(p)Fails to develop, maintain, and retain, in accordance with relevant rules and standards, adequate financial records that document charges incurred by a client and payments received from any source;
(q)Fails to follow generally accepted accounting principles or accounting standards or cost principles required by federal or state laws, rules, or regulation;
(r)Submits claims for services provided that were contrary to generally accepted standards of medical practice;
(s)Submits claims for services that exceed that requested or agreed to by the client or the responsible relative or guardian or requested by another medical practitioner;
(t)Breaches the terms of the medical services agreement;
(u)Fails to correct deficiencies in operations after receiving written notice of the deficiencies from the Center;
(v)Fails to submit a billing error edit correction within 30 days of receipt of the third party payment or to refund the appropriate amount within this time frame;
(w)Provides or bills for services provided by ineligible or unsupervised staff;
(x)Submits claims for payment, either personally or through claims submitted by any billing provider or other provider, for any services or supplies provided under the WW Program for services provided after being suspended or terminated from participation in a federal or state medical program, such as Medicare or Medicaid, or after his or her license to practice has been suspended or revoked by a state licensing board;
(y)Fails to notify the Center of a change of TIN within 30 days; or
(z)Fails to respond to a request for records under OAR 333-010-0270 (Requirements for Financial, Clinical and Other Records).
(2)Sanctions may include:
(a)Termination from participation in the WW Program;
(b)Suspension from participation in the WW Program for a specified length of time, or until specified conditions for reinstatement are met and approved by the Center;
(c)Withholding payments to an enrolling or ancillary provider;
(d)A requirement to attend provider education sessions at the expense of the sanctioned enrolling or ancillary provider;
(e)A requirement that payment for certain services are made only after the Center has reviewed documentation supporting the services;
(f)The recovery of investigative and legal costs;
(g)Reduction of any amount otherwise due the enrolling or ancillary provider; and the reduction may be up to three times the amount a provider sought to collect from a client;
(h)Any other sanction reasonably designed to remedy or compel future compliances with federal, state or Center regulations.
(3)An enrolling or ancillary provider who has been the subject of repeat sanctions regarding improper billing practices may be liable to the Center for up to triple the amount of the established overpayment received as a result of such violation.
(4)When an enrolling or ancillary provider fails to meet one or more of the requirements identified in this rule the Center, at its sole discretion, may immediately suspend the provider’s BCCP/WW Program assigned billing number to prevent public harm or inappropriate expenditure of public funds.
(a)An enrolling or ancillary provider subject to immediate suspension is entitled to a contested case hearing as outlined in OAR 333-010-0290 (Provider Appeals (Level 2) — Contested Case Hearing) to determine whether the provider’s BCCP/WW Program assigned number will be revoked.
(b)The notice requirements described in section (5) of this rule does not preclude immediate suspension at the Center’s sole discretion to prevent public harm or inappropriate expenditure of public funds. Suspension may be invoked immediately while the notice and contested case hearing rights are exercised.
(5)If the Center decides to sanction an enrolling or ancillary provider, the Center shall notify the provider by certified mail or personal delivery service of the intent to sanction. The notice of immediate or proposed sanction will identify:
(a)The factual basis used to determine the alleged deficiencies;
(b)Explanation of actions expected of the provider;
(c)Explanation of subsequent actions the Center intends to take;
(d)The provider’s right to dispute the Center’s allegations, and submit evidence to support the provider’s position; and
(e)The provider’s right to appeal the Center’s proposed actions pursuant to OAR 333-010-0285 (Provider Appeals (Level 1) — Claims Reconsideration) through 333-010-0290 (Provider Appeals (Level 2) — Contested Case Hearing).
(6)If the Center makes a final decision to sanction an enrolling or ancillary provider, the Center shall notify the provider in writing at least 15 days before the effective date of action, except in the case of immediate suspension to avoid public harm or inappropriate expenditure of funds.
(7)An enrolling or ancillary provider must appeal an immediate or proposed sanction separately from any appeal of audit findings and overpayments.
Rule 333-010-0280 — Provider Sanctions,