Type and Conditions of Sanction
(1)The Division of Medical Assistance Programs (Division) may impose mandatory Sanctions on a Provider pursuant to OAR 410-120-1400 (Provider Sanctions)(3), in which case:
(a)The Provider will be either Terminated or Suspended from participation in Oregon’s medical assistance programs;
(b)If Suspended, the minimum duration of suspension will be determined by the Secretary of the Department of Health and Human Services (DHHS), under the provisions of 42 CFR Parts 420, 455, 1001, or 1002. The State may suspend a Provider from participation in Oregon’s medical assistance programs longer than the minimum suspension determined by the DHHS Secretary.
(2)The Division may impose the following discretionary Sanctions on a Provider pursuant to OAR 410-120-1400 (Provider Sanctions)(4):
(a)The provider may be Terminated from participation in Oregon’s medical assistance programs;
(b)The provider may be suspended from participation in Oregon’s medical assistance programs for a specified length of time, or until specified conditions for reinstatement are met and approved by Division;
(c)The Division may withhold payments to a provider;
(d)The Provider may be required to attend provider education sessions at the expense of the Sanctioned Provider;
(e)The Division may require that payment for certain services are made only after the Division has reviewed documentation supporting the services;
(f)The Division may recover investigative and legal costs;
(g)The Division may provide for reduction of any amount otherwise due the Provider; and the reduction may be up to three times the amount a Provider sought to collect from a client in violation of OAR 410-120-1280 (Billing);
(h)Any other Sanctions reasonably designed to remedy or compel future compliances with federal, state or Division regulations.
(3)The Division will consider the following factors in determining the Sanction(s) to be imposed (this list includes but is not limited to these factors):
(a)Seriousness of the offense(s);
(b)Extent of violations by the Provider;
(c)History of prior violations by the Provider;
(d)Prior imposition of Sanctions;
(e)Prior Provider education;
(f)Provider willingness to comply with program rules;
(g)Actions taken or recommended by licensing boards or a Quality Improvement Organization (QIO); and
(h)Adverse impact on the health of Division clients living in the Provider’s service area.
(4)When a Provider fails to meet one or more of the requirements identified in this rule the Division, at its sole discretion, may immediately suspend the provider’s Division assigned billing number to prevent public harm or inappropriate expenditure of public funds:
(a)The provider subject to immediate suspension is entitled to a contested case hearing as outlined in 410-120-1600 (Provider Appeals — Contested Case Hearings) through 410-120-1700 to determine whether the provider’s Division assigned number will be revoked;
(b)The notice requirements described in section (5) of this rule do not preclude immediate suspension at the Division’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 Division decides to Sanction a Provider, the Division will 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 Division intends to take;
(d)The Provider’s right to dispute the Division’s allegations, and submit evidence to support the provider’s position; and
(e)The Provider’s right to appeal Division’s proposed actions pursuant to OARs 410-120-1560 (Provider Appeals) through 410-120-1700.
(6)If the Division makes a final decision to Sanction a provider, the Division will 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)The provider may appeal the Division’s immediate or proposed Sanction(s) or other action(s) the Authority intends to take, including but not limited to the following list. The provider must appeal these actions separately from any appeal of audit findings and overpayments:
(a)Termination or suspension from participation in the Medicaid-funded medical assistance programs;
(b)Termination or suspension from participation in the Division’s state-funded programs;
(c)Revocation of the provider’s the Division assigned provider number.
(a)When a Provider has been Sanctioned, all other Provider entities in which the Provider has ownership (five percent or greater) or control of, may also be Sanctioned;
(b)When a provider has been Sanctioned, the Division may notify the applicable professional society, board of registration or licensure, federal or state agencies, Oregon Health Plan Prepaid Health Plans and the National Practitioner Data Base of the findings and the Sanctions imposed;
(c)At the discretion of the Division, providers who have previously been Terminated or Suspended may or may not be re-enrolled as Division providers;
(d)Nothing in this rule prevents the Authority from simultaneously seeking monetary recovery and imposing Sanctions against the provider;
(e)If the Division discovers continued improper billing practices from a provider who, after having been previously warned in writing by the Division or the Department of Justice about improper billing practices and has had an opportunity for a contested case hearing, that provider will be liable to the Division for up to triple the amount of the Division’s established overpayment received as a result of such violation.
Rule 410-120-1460 — Type and Conditions of Sanction,