La. Admin. Code tit. 50 § I-4103
Affiliate - any person who has a direct or indirect relationship or association with a provider such that the provider is directly or indirectly influenced or controlled by the affiliate or has the power to do so. Any person with a direct or indirect ownership interest in a provider is presumed to be an affiliate of that provider. Any person who shares in the proceeds or has the right to share in the proceeds of a provider is presumed to be an affiliate of that provider unless that person is a spouse or a minor child of the provider and has no other affiliation with the provider other than that of being a family member of the provider.
Agent - a person who is employed by or has a contractual relationship with a provider or who acts on behalf of the provider.
Agreement to Repay - a formal written and enforceable arrangement to repay an identified overpayment, interest, monetary penalties or costs and expenses.
Billing Agent - any agent who performs any or all of the provider's billing functions. Billing agents are presumed to be an agent of the provider.
Billing or Bill - submitting, or attempting to submit, a claim for goods, supplies, or services.
Claim - any request or demand, including any and all documents or information required by federal or state law or by rule made against Medical Assistance Program funds for payment. A claim may be based on costs or projected costs and includes any entry or omission in a cost report or similar document, book of account, or any other document which supports, or attempts to support, the claim. Each claim may be treated as a separate claim, or several claims may be combined to form one claim.
Claims or Payment Review - the process of reviewing documents or other information or sources required or related to the payment or reimbursement to a provider by the department, the department's contractor(s), BHSF, SURS, or the fiscal intermediary in order to determine if the bill or claim should be or should have been paid or reimbursed. Payment and claim reviews are the same process.
Contractor - any person with whom the provider has a contract to perform a service or function on behalf of the provider. A contractor is presumed to be an agent of the provider.
Corrective Action Plan - a written plan, short of an administrative sanction, agreed to by a provider, provider-in-fact or other person with the department, BHSF, or Program Integrity designed to remedy any inefficient, aberrant or prohibited practices by a provider, provider-in-fact or other person. A corrective action plan is not a sanction.
Credible Allegation of Fraud -
Department - the Louisiana Department of Health and Hospitals.
Deputy Secretary - the deputy secretary of the department or authorized designee.
Director of Bureau of Health Services Financing - the director of BHSF or authorized designee.
Director of Program Integrity or Assistant Director of Program Integrity - the individual whom the secretary has designated as the director, program manager or section chief of the Program Integrity Division or the designated assistant to the director of Program Integrity Division respectively or their authorized designee.
Exclusion from Participation - a sanction that terminates a provider, provider-in-fact or other person from participation in the Medicaid Program, and cancels the provider's provider agreement.
False or Fraudulent Claim - a claim which the provider or his billing agent submits knowing the claim to be false, fictitious, untrue, or misleading in regard to any material information. False or fraudulent claim shall include a claim which is part of a pattern of incorrect submissions in regard to material information or which is otherwise part of a pattern in violation of applicable federal or state law, rule, or policy.
Federal Regulations - the provisions contained in the Code of Federal Regulations (CFR) or the Federal Register (FR).
Finalized Sanction or Final Administrative Adjudication or Order - a final order imposed pursuant to an administrative adjudication that has been signed by the secretary or the secretary's authorized designee.
Fiscal Agent or Fiscal Intermediary - an organization or legal entity with whom the department contracts to provide for the processing, review of or payment of provider bills and claims.
Good, Service, or Supply - any good, item, device, supply, or service for which a claim is made, or is attempted to be made, in whole or in part.
Health Care Provider - any person furnishing or claiming to furnish a good, service, or supply under the Medical Assistance Programs as defined in R.S. 46:437.3 and any other person defined as a health care provider by federal or state law or by rule. For the purpose of this Chapter, health care provider and provider are interchangeable terms.
Identified Overpayment - the amount of overpayment made to or requested by a provider that has been identified in a final administrative adjudication or order.
Indirect Ownership - the owner has an ownership interest in the provider through some other entity, whether said ownership interest, at any level, is in whole or in part.
Ineligible Recipient - an individual who is not eligible to receive health care through the medical assistance programs.
Informal Hearing - an informal conference between the provider, provider-in-fact, or other persons and the director of Program Integrity or his/her designee related to a notice of corrective action, notice of withholding of payments or notice of sanction.
Investigator or Analyst - any person authorized to conduct investigations on behalf of the department, BHSF, Program Integrity, SURS, or the fiscal intermediary, either through employment or contract for the purposes of payment or programmatic review.
Investigatory Process - the examination of the provider, provider-in-fact, agent-of-the-provider, or affiliate, and any other person or entity, and any and all records held by or pertaining to them pursuant to a written request from BHSF. No adjudication is made during this process.
Knew or Should Have Known - the person knew or should have known that the activity engaged in or not engaged in was prohibited conduct under this regulation or federal or state laws and regulations. The standard to be used in determining knew or should have known is that of a reasonable person engaged in the activity or practice related to the Medical Assistance Program at issue.
Knowing or Knowingly - the person has actual knowledge of the information, or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information. The standard to be used in determining knowing or knowingly is that of a reasonable person engaged in the activity or practice related to the Medical Assistance Program at issue.
Law - any written constitution, statutory laws, rules, collection of rules, or code prescribed under the authority of the governments of the state of Louisiana or the United States.
Louisiana Administrative Code (LAC) - the Louisiana Administrative Code.
Managing Employee - a person who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operations of a provider. Managing employee shall include, but is not limited to, a chief executive officer, president, general manager, business manager, administrator, or director.
Medical Assistance Program or Medicaid - the Medical Assistance Program (Title XIX of the Social Security Act), commonly referred to as Medicaid, and other programs operated by and funded in the department, which provide payment to providers.
Misrepresentation - the knowing failure to truthfully or fully disclose any and all information required, or the concealment of any and all information required on a claim or a provider agreement or the making of a false or misleading statement to the department relative to the Medical Assistance Program.
Notice - actual or constructive notice.
Notice of an Action - a written notification of an action taken or to be taken by the department, BHSF or SURS. A notice must be signed by or on behalf of the secretary, director of BHSF, or director of Program Integrity.
Ownership Interest - the possession, directly or indirectly, of equity in the capital or the stock, or right to share in the profits of a provider.
Payment or Reimbursement - the payment or reimbursement to a provider from Medical Assistance Programs' funds pursuant to a claim, or the attempt to seek payment for a claim.
Person - any natural person, company, corporation, partnership, firm, association, group, or other legal entity or as otherwise provided for by law.
Policies, Criteria or Procedure - those things established or provided for through departmental manuals, provider updates, remittance advice, memorandums, or bulletins issued by the Medical Assistance Program or the department.
Program - any program authorized under the Medical Assistance Program.
Program Integrity Division (PID) - the Program Integrity Unit under BHSF within the department, its predecessor and successor.
Provider Agreement - the document(s) signed by or on behalf of the provider and those things established or provided for in R.S. 46:437.11-437.14 or by rule, which enrolls the provider in the Medical Assistance Program or one or more of its programs and grants to the provider a provider number and the privilege to participate in the Medicaid Program or one or more of its programs.
Provider Enrollment - the process through which a person becomes enrolled in the Medical Assistance Program or one of its programs for the purpose of providing goods, services, or supplies to one or more Medicaid recipients.
Provider-in-Fact - person who directly or indirectly participates in management decisions, has an ownership interest in the provider, or other persons defined as a provider-in-fact by federal or state law or by rule. A person is presumed to be a provider-in-fact if the person is:
Provider Number - a provider's billing or claim reimbursement number issued by the department through BHSF under the Medical Assistance Program.
Recipient - an individual who is eligible to receive health care through the medical assistance programs.
Recoupment - recovery through the reduction, in whole or in part, of payments or reimbursements to a provider.
Recovery - the recovery of overpayments, damages, fines, penalties, costs, expenses, restitution, attorney fees, or interest or settlement amounts.
Referring Provider - any provider, provider-in-fact or anyone operating on the provider's behalf who refers a recipient to another person for the purpose of providing goods, services, or supplies.
Rule or Regulation - any rule or regulation promulgated by the department in accordance with the Administrative Procedure Act and any federal rule or regulation promulgated by the federal government in accordance with federal law.
Secretary - the secretary of the Department of Health and Hospitals, or his authorized designee.
Statistical Sample - a statistical formula and sampling technique used to produce a statistical extrapolation of the amount of overpayment made to a provider.
SURS Manager - the individual designated by the secretary as the manager of SURS or authorized designee.
Surveillance and Utilization Review Subsystem (SURS) - the section within the department assigned to identify providers for review, conduct payment reviews, and sanction providers resulting from payments to and claims from providers, and any other functions or duties assigned by the secretary.
Undersecretary - the undersecretary of the department or authorized designee.
Violations - any practice or activity by a provider, provider-in-fact, agent-of-the-provider, affiliate, or other persons which is prohibited by law or this Chapter.
Withhold Payment - to reduce or adjust the amount, in whole or in part, to be paid to a provider for pending or future claims during the time of a criminal, civil, or departmental investigation, departmental proceeding, or claims review of the provider.
Working Days - Monday through Friday, except for legal holidays and other situations when the department is closed.
La. Admin. Code tit. 50, § I-4103