Section 405 IAC 1-1.4-4 - Sanctions against providers; determination after investigationAuthority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-21.5-3-6; IC 4-21.5-3-7; IC 4-21.5-4; IC 12-15
Sec. 4.
(a) If, after investigation by the office, the IMFCU, or other governmental authority, the office determines that a provider has violated any provision of IC 12-15, or has violated any rule established under one (1) of those sections, the office may impose one (1) or more of the following sanctions: (1) Deny payment to the provider for Medicaid services rendered during a specified period of time as provided under section 8 of this rule.(2) Reject a prospective provider's application for participation in Medicaid.(3) Remove a provider's certification for participation in Medicaid (decertify the provider).(4) Assess a fine against the provider in an amount not to exceed three (3) times the amounts paid to the provider in excess of the amounts that were legally due.(5) Require the provider to create a corrective action plan. A corrective action plan must include the following: (A) A timeline for coming into compliance with state or federal requirements.(B) The names, including title, address, and phone number, of persons responsible for ensuring compliance with state or federal requirements.(C) A description of the actions the entity will take to come into compliance with state or federal requirements.(D) Any other information required by the office. If, after sixty (60) calendar days following written notice of a request for a corrective action plan by the state, a provider has not submitted a corrective action plan, the provider may be subject to payment withholding or any other sanction under this rule.
(6) Suspend a provider's Medicaid payments in whole or in part.(7) Terminate the provider agreement.(b) Specifically, the office may impose the sanctions in subsection (a) if, after investigation by the office, the IMFCU, or other governmental authority, the office determines that the provider:(1) presented or knowingly submitted:(A) claims for Medicaid services:(i) that cannot be documented by the provider; or(ii) provided to a person other than a person in whose name the claim is made;(B) any false or fraudulent claims for Medicaid services or merchandise;(C) information with the intent of obtaining greater compensation than that which the provider is legally entitled, including charges in excess of the:(ii) usual and customary charges; or(D) false information for the purpose of meeting prior authorization requirements;(2) engaged in a course of conduct or performed an act deemed by the office to be abusive of the Medicaid program or continuing the conduct following notification that the conduct should cease;(3) knowingly breached the terms of the Medicaid provider certification agreement;(4) failed to comply with the terms of the provider certification on the Medicaid claim form;(5) knowingly overutilized the Indiana Medicaid program or otherwise caused the member to receive services or merchandise not otherwise required or requested by the member;(6) knowingly submitted: (A) a false or fraudulent provider agreement;(B) claims for Medicaid services for which federal financial participation is not available; or(C) any claims for Medicaid services or merchandise arising out of any act or practice prohibited by the: (i) criminal provisions of the Indiana Code; or (ii) rules of the office;(7) failed to: (A) disclose or make available to the office, the IMFCU, or other governmental authority, after reasonable request and notice to do so, documentation of services provided to Medicaid members and Medicaid records of payments made therefor;(B) comply with the requirements of 1902(a)(68) of the Social Security Act, except that such failure shall first be sanctioned with a corrective action plan before any other sanction in subsection (a) shall be applied; or(C) meet standards required by the state of Indiana or federal law for participation;(8) knowingly charged a Medicaid member for covered services over and above that paid for by the office;(9) refused to execute a new provider agreement when requested to do so;(10) failed to: (A) correct deficiencies to provider operations after receiving written notice of these deficiencies from the office; or(B) repay or make arrangements for the repayment of identified overpayments or otherwise erroneous payments in accordance with state or federal law; or(11) knowingly billed Medicaid more than the usual and customary charge to the provider's private pay customers.(c) The office may impose a sanction under IC 4-21.5-3-6. Any order issued under this subsection shall:(1) be served upon the provider by certified mail, return receipt requested;(2) contain a brief description of the order;(3) become final fifteen (15) days after its receipt; and(4) contain a statement that any appeal from the decision of the office made under this section shall be taken in accordance with IC 4-21.5-3-7 and section 12 of this rule.(d) If an emergency exists, as determined by the office, the office may issue an emergency order imposing a sanction identified in this section under IC 4-21.5-4. Any order issued under this subsection shall:(1) be served upon the provider by certified mail, return receipt requested;(2) become effective upon receipt;(3) include a brief statement of the facts and law that justifies the office's decision to issue an emergency order; and(4) contain a statement that any appeal from the decision of the office made under this section shall be taken in accordance with IC 4-21.5-3-7 and section 12 of this rule.(e) The decision to impose a sanction shall be made at the discretion of the office.(f) Prepayment review of provider claims is not a sanction and is not subject to appeal.Office of the Secretary of Family and Social Services; 405 IAC 1-1.4-4; filed 12/21/2018, 3:17 p.m.: 20190116-IR-405180251FRAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA