016.06.10 Ark. Code R. 007

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.10-007 - Section I Provider Manual Update Transmittal

142.500 Conditions Related to Fraud and Abuse

A. Any provider who engages in fraudulent billing practices will be immediately suspended from participation until these practices are evaluated and resolved. Also, any provider discovered to be involved in fraudulent billing practices or found to be accepting or soliciting unearned rebates, refunds or other unearned considerations, whether in the form of money or otherwise, will be referred to the appropriate legal agency for prosecution under applicable federal or state laws.

B. Any provider who engages in abuse or over-utilization of services provided to Medicaid beneficiaries, when such abuse or over-utilization has been determined by DMS professional staff, medical consultants, contractors or designees, may be terminated from participation in the Medicaid Program, required to repay monies paid by the Medicaid Program for such services or have other appropriate action taken upon recommendation of the above-referenced parties.

C. Except where participation has been terminated, each provider who has been sanctioned may be required to participate ina provider education program as a condition of continued participation. Provider education programs will include, at a minimum, the following:

1. Instruction on admissions and authorization for payments

2. Instruction on the use and format of required program forms

3. Instruction on key provisions of the Medicaid Program

4. Instruction on reimbursement rates

5. Instruction on how to inquire about program requirements, payment or billing problems and the overall operation of the program

D. Providers are obligated to screen all employees and contractorsto determine; if any of them are excluded from participation in Federal health care programs.

1. Providers can search the LEIE website maintained by the United States Health and Human Services Office of Inspector General which contains the names of any excluded individual or, entity.

(http://www.oia.hhs.aov/fraud/exclusions.asp). The United States Genercal Services Administration maintains a list of excluded providers at https://www.epls.gov/. Providers should search the website monthly |q capture exclusions and reinstatements that have occurred since the last search..

2. Providers can find a Department of Human Services excluded list on the Arkansas Department of Human Services website at: https://ardhs.sharepointsite.net/ExcludedProvidersList/Excluded%20Provided%20List.html. This list contains the names of any excluded individuals or entities. The Arkansas Department of Finance and Administration, Office of State Procurement, maintains a list of suspended or debarredivendprstat: http://www.dfa.arkansas.aov/offices/procurement/auidelines/Paqes/suspendedDebarredVendors.aspx

3. If providers discover any exclusion information other that what is provided on the websites, providers should report that information to Provider Enrollment.

4. Providers should check the websites monthly to capture exclusions and reinstatements which may have occurred since the last search.

E. No Medicaid payments can be made for any times or services directed or prescribed by an excluded provider; or any other authorized person, when the individual entity furnishing the services knew or should have known of the exclusion. This prohibition applies even when the Medicaid payment itself is made to another provider, practitioner or supplier that is not excluded. (See 42 CFR section 1001.1901(b)).The following listing sets forth examples of types of services that are reimbursed by Medicaid which, when provided by excluded parties, are not reimbursable:

1. Nurses, technicians or other excluded individuals who work for a hospital, nursing home, home health agency or physician practice, where such services are related to administrative duties, preparation of surgical trays or review of treatment plans if such services are reimbursed directly or indirectly by a Medicaid program, even if the individuals do not furnish direct medical care to Medicaid beneficiaries.

2. Services performed by excluded pharmacists or other excluded individuals who input prescription information for pharmacy billing or who-are involved in any way infilling prescriptions for drugs reimbursed directly or indirectly by a Medicaid program.

3. Services performed by excluded ambulance drivers, dispatchers or other employee's patients or nursing home residents.

4. Services performed for program beneficiaries by excluded individuals who sell, deliver or refill orders for medical'devices or equipment being reimbursed by a Medicaid program.

5. Services performed by excluded social workers who are employed by health care entities to provide services to Medicaid beneficiaries and whose services are reimbursed, directly or indirectly by a Medicaid program.

6., Services performed by an excluded administrator, billing agent, accountant,

claims processor or utilization reviewer that are related to and reimbursed, directly or indirectly by a Medicaid program.

7. Items or services provided to a Medicaid beneficiary by an excluded individual who works for an entity that has a contractual agreement with, and is paid by, a Medicaid program.

8. Items or equipment "sold by an excluded manufacturer or supplier, used in the care or treatment of beneficiaries and reimbursed, directly or indirectly by a Medicaid program.

F. Civil monetary penalties may be imposed against Medicaid providers who employ or enter into contracts with excluded individuals or entities to provider items or services to Medicaid beneficiaries. (See 1128A (a) (6) of the Act and 42 CFR section 1003.102(a) (2) .)

016.06.10 Ark. Code R. 007

5/14/2010