Oregon Oregon Health Authority, Health Systems Division: Medical Assistance Programs

Rule Rule 410-120-1400
Provider Sanctions

(1) The Authority recognizes two classes of provider sanctions, mandatory and discretionary, outlined in sections (3) and (4) below.
(2) Except as otherwise noted, the Authority shall impose provider sanctions at the discretion of the Authority Director or the Administrator of the Division whose budget includes payment for the services involved.
(3) The Authority’s Health Systems Division (Division) shall impose mandatory sanctions and suspend the provider from participation in Oregon’s medical assistance programs:
(a) When a provider of medical services is convicted (as that term is defined in 42 CFR 1001.2) 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;
(b) When a provider is excluded from participation in federal or state health care programs by the Office of the Inspector General of the U.S. Department of Health and Human Services or from the Medicare (Title XVIII) program of the Social Security Act as determined by the Secretary of Health and Human Services. The provider shall be excluded and suspended from participation with the Division for the duration of exclusion or suspension from the Medicare program or by the Office of the Inspector General;
(c) If the provider fails to disclose ownership or controlling information required under 42 CFR 455.104 that is required to be reported at the time the provider submits a provider enrollment application, or when there is a material change in the information that must be reported or information related to business transactions required to be provided under 42 CFR 455.105 upon request of federal or state authorities.
(4) The Division may impose discretionary sanctions when the Division determines that the provider fails to meet one or more of the Division’s requirements governing participation in its medical assistance programs. Conditions that may result in a discretionary sanction include but are not limited to when a provider is:
(a) Convicted of fraud related to any federal, state, or locally financed health care program or commits fraud, receives kickbacks, or commits other acts that are subject to criminal or civil penalties under the Medicare or Medicaid statutes;
(b)Convicted of interfering with the investigation of health care fraud;
(c) Convicted of unlawfully manufacturing, distributing, prescribing, or dispensing a controlled substance;
(d) By findings or actions of any state licensing authority for reasons relating to the provider’s professional competence, professional conduct, quality of care, or financial integrity including but not limited to:
(A) Having the health care license suspended or revoked, or otherwise loses their license; or
(B) Surrendering their license while a formal disciplinary proceeding is pending before the licensing authority.
(e) Suspended or excluded from participation in any federal or state health care program for reasons related to professional competence, professional performance, or other reason;
(f) Bills excessive charges (i.e., charges more than the usual charge). Furnishes items or services substantially more than the Division client’s needs or more than those services ordered by a medical provider or more than generally accepted standards or of a quality that fails to meet professionally recognized standards;
(g) Fails to furnish medically necessary services as required by law or contract with the Division if the failure has adversely affected (or has a substantial likelihood of adversely affecting) the Division client;
(h) Fails to disclose required ownership information;
(i) Fails to supply requested information on subcontractors and suppliers of goods or services;
(j) Fails to supply requested payment information;
(k) Fails to grant access or to furnish as requested, records, or grant access to facilities upon request of the Division or the State of Oregon’s Medicaid Fraud Unit conducting their regulatory or statutory functions;
(L) In the case of a hospital, fails to take corrective action as required by the Division, based on information supplied by the Quality Improvement Organization to prevent or correct inappropriate admissions or practice patterns, within the time specified by the Division;
(m) Defaults on repayment of federal or state government scholarship obligations or loans in connection with the provider’s health profession education. The Division:
(A) Must make a reasonable effort to secure payment;
(B) Must take into account access of beneficiaries to services; and
(C) May not exclude a community’s sole physician or source of essential specialized services.
(n) Repeatedly submits a claim with required data missing or incorrect:
(A) When the missing or incorrect data allows the provider to:
(i) Obtain greater payment than is appropriate;
(ii) Circumvent prior authorization requirements;
(iii) Charge more than the provider’s usual charge to the general public;
(iv) Receive payments for services provided to persons who are not eligible;
(v) Establish multiple claims using procedure codes that overstate or misrepresent the level, amount, or type of health care provided.
(B) Fails to comply with the requirements of OAR 410-120-1280 (Billing) (Billing).
(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 develop, maintain, and retain adequate financial or other records that support information submitted on a cost report;
(r) Fails to follow generally accepted accounting principles or accounting standards or cost principles required by federal or state laws, rules, or regulations;
(s) Submits claims or written orders contrary to generally accepted standards of medical practice;
(t) 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 provider;
(u) Breaches the terms of the provider contract or agreement. This includes failure to comply with the terms of the provider certifications on the medical claim form;
(v) Rebates or accepts a fee or portion of a fee or charge for an Division client referral, or collects a portion of a service fee from the client and bills the Division for the same service;
(w) Submits false or fraudulent information when applying for the Division assigned provider number, or fails to disclose information requested on the provider enrollment application;
(x) Fails to correct deficiencies in operations after receiving written notice of the deficiencies from the Division;
(y) Submits any claim for payment for which payment has already been made by the Division or any other source unless the amount of the payment from the other source is clearly identified;
(z) Threatens, intimidates, or harasses clients or their relatives in an attempt to influence payment rates or affect the outcome of disputes between the provider and the Division;
(aa) Fails to properly account for a Division client’s Personal Incidental Funds, including but not limited to using a client’s Personal Incidental Funds for payment of services that are included in a medical facility’s all-inclusive rates;
(bb) Provides or bills for services provided by ineligible or unsupervised staff;
(cc) Participates in collusion that results in an inappropriate money flow between the parties involved; for example, referring clients unnecessarily to another provider;
(dd) Refuses or fails to repay in accordance with an accepted schedule an overpayment established by the Division;
(ee) Fails to report to Division payments received from any other source after the Division made payment for the service;
(ff) Failure to comply with the requirements listed in OAR 410-120-1280 (Billing)(Billing).
(5) A provider excluded, suspended, or terminated from participation in a federal or state medical program, such as Medicare or Medicaid, or whose license to practice is suspended or revoked by a state licensing board may not submit claims for payment, either personally or through claims submitted by any billing agent/service, billing provider, or other provider for any services or supplies provided under the medical assistance programs, except those services or supplies provided prior to the date of exclusion, suspension, or termination.
(6) Providers may not submit claims for payment to the Division for any services or supplies provided by an individual or provider entity that is excluded, suspended, or terminated from participation in a federal or state medical program or whose license to practice is suspended or revoked by a state licensing board, except for those services or supplies provided prior to the date of exclusion, suspension, or termination.
(7) When the provisions of sections (5) or (6) are violated, the Division may suspend or terminate the billing provider or any individual performing provider within said organization who is responsible for the violation.

Last accessed
Jun. 8, 2021