Fraud and Abuse
(1)This rule sets forth requirements for reporting, detecting and investigating fraud and abuse. The terms fraud and abuse are defined in OAR 410-120-0000 (Acronyms and Definitions). For the purpose of these rules, the following definitions apply:
(a)“Credible allegation of fraud” means an allegation of fraud, that has been verified by the state and has indicia of reliability that comes from any source as defined in 42 CFR 455.2;
(b)“Conviction” or “convicted” means that a judgment of conviction has been entered by a federal, state, or local court regardless of whether an appeal from that judgment is pending;
(c)“Exclusion” means that the Authority or the Department of Human Services (Department) shall not reimburse a specific provider who has defrauded or abused the Authority or Department for items or services which that provider furnished;
(d)“Prohibited kickback relationships” means remuneration or payment practices that may result in federal civil penalties or exclusion for violation of 42 CFR 1001.951;
(e)“Suspension” means the Authority or Department shall not reimburse a specified provider who has been convicted of a program-related offense in a federal, state, or local court for items or services which that provider furnished.
(2)Cases involving one or more of the following situations shall constitute sufficient grounds for a provider fraud referral:
(a)Billing for services, supplies, or equipment that are not provided to or used for Medicaid patients;
(b)Billing for supplies or equipment that are clearly unsuitable for the patient’s needs or are so lacking in quality or sufficiency for the purpose as to be virtually worthless;
(c)Claiming costs for non-covered or non-chargeable services, supplies, or equipment disguised as covered items;
(d)Materially misrepresenting dates and descriptions of services provided, and the identity of the individual who provided the services or of the recipient of the services;
(e)Duplicate billing of the Medicaid program or of the recipient that appears to be a deliberate attempt to obtain additional reimbursement; and
(f)Arrangements by providers with employees, independent contractors, suppliers, and other various devices such as commissions and fee splitting that appear to be designed primarily to obtain or conceal illegal payments or additional reimbursement from Medicaid.
(3)The provider shall promptly refer all suspected fraud and abuse, including fraud or abuse by its employees or in the Division administration, to the Medicaid Fraud Control Unit (MFCU) of the Department of Justice or to the Department’s Provider Audit Unit (PAU). Contact information may be found online at: http://www.oregon.gov/OHA/HSD/OHP//Pages/Policy-General-Rules.aspx.
(4)If the provider is aware of suspected fraud or abuse by an Authority or Department client, the provider shall report the incident to the Department’s Fraud Investigations Unit (FIU). Contact information may be found online at http://www.oregon.gov/OHA/HSD/OHP//Pages/Policy-General-Rules.aspx.
(5)The provider shall permit the MFCU, Authority, Department, or law enforcement entity, together or separately, to inspect, copy, evaluate, or audit books, records, documents, files, accounts, and facilities without charge, as required to investigate an incident of fraud or abuse. When a provider fails to provide immediate access to records, Medicaid payments may be withheld or suspended.
(6)Providers and their fiscal agents shall disclose ownership and control information and disclose information on a provider’s owners and other persons convicted of criminal offenses against Medicare, Medicaid, CHIP, or the Title XX services program. Such disclosure and reporting is made a part of the provider enrollment agreement, and the provider shall update that information with an amended provider enrollment agreement if any of the information materially changes. The Authority or Department shall use that information to meet the requirements of 42 CFR 455.100 (Duties of director) to 455.106, and this rule shall be construed in a manner that is consistent with the Authority or Department acting in compliance with those federal requirements.
(7)The Authority or Department may share information for health oversight purposes with the MFCU and other federal or state health oversight authorities.
(8)The Authority or Department may suspend payments in whole or part in a suspected case of fraud or abuse; or where there exists a credible allegation of fraud or abuse presented to the Authority, the Department, or law enforcement entity; or where there is a pending investigation or conclusion of legal proceedings related to the provider’s alleged fraud or abuse.
(9)The Authority or Department may take the actions necessary to investigate and respond to credible allegations of fraud and abuse, including but not limited to suspending or terminating the provider from participation in the medical assistance programs, withholding payments or seeking recovery of payments made to the provider, or imposing other sanctions provided under state law or regulations. These actions by the Authority or Department may be reported to CMS, or other federal or state entities as appropriate.
(10)The Authority or Department shall not pay for covered services provided by persons who are currently suspended, debarred, or otherwise excluded from participating in Medicaid, Medicare, CHIP, or who have been convicted of a felony or misdemeanor related to a crime or violation of Title XVIII, XIX, XXI, or XX of the Social Security Act or related laws.
Rule 410-120-1510 — Fraud and Abuse,