La. Admin. Code tit. 50 § I-4101

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-4101 - Foreword

A. The Medical Assistance Program is a four-party arrangement: the taxpayer; the government; the beneficiaries; and the providers. The secretary of the Department of Health and Hospitals (DHH), through this Chapter 41, recognizes:

1. the obligation to the taxpayers to assure the fiscal and programmatic integrity of the Medical Assistance Program. The secretary has zero tolerance for fraudulent, willful, abusive or other ill practices perpetrated upon the Medical Assistance Program by providers, providers-in-fact and others, including beneficiaries. Such practices will be vigorously pursued to the fullest extent allowed under the applicable laws and regulations; and

2. the responsibility to assure that actions brought in pursuit of providers, providers-in-fact and others, including beneficiaries, under this regulation are not frivolous, vexatious or brought primarily for the purpose of harassment. Providers, providers-in-fact and others, including beneficiaries, must recognize that they have an obligation to obey and follow all applicable laws, regulations, policies, criteria, and procedures.

B. The Department of Health and Hospitals, Bureau of Health Services Financing (BHSF) has adopted this Chapter 41 in order to:

1. establish procedures for conducting surveillance and utilization review of providers and others;

2. define conduct in which providers and others cannot be engaged;

3. establish grounds for sanctioning providers and others who engage in prohibited conduct; and

4. establish the procedures to be used when sanctioning or otherwise restricting a provider and others under the Medicaid Program.

C. The purpose of this regulation is to assure the quality, quantity, and need for such goods, services, and supplies and to provide for the sanctioning of those who do not provide adequate goods, services, or supplies or request payment or reimbursement for goods, services, or supplies which do not comply with the requirements of federal laws, federal regulations, state laws, state regulations, or the rules, procedures, criteria or policies governing providers and others under the Medicaid Program.

D. A further purpose of this regulation is to assure the integrity of the Medicaid Program by providing methods and procedures to:

1. prevent, detect, investigate, review, hear, refer, and report fraudulent or abusive practices, errors, over-utilization, or under-utilization by providers and others;

2. impose any and all administrative sanctions and remedial measures authorized by law or regulation, which are appropriate under the circumstances;

3. pursue recoupment or recovery arising out of prohibited conduct or overpayments;

4. allow for informal resolution of disputes between the Louisiana Medicaid Program and providers and others;

5. establish rules, policies, criteria and procedures; and

6. other functions as may be deemed appropriate.

E. Nothing in this Chapter 41 is intended, nor shall it be construed, to grant any person any right to participate in the Medicaid Program which is not specifically granted by federal law or the laws of this state or to confer upon any person's rights or privileges which are not contained within this regulation.

La. Admin. Code tit. 50, § I-4101

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 25:1630 (September 1999), repromulgated LR 29:584 (April 2003), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38: 2774 (November 2012).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance Program Integrity Law).