Title: Section 516.1 - Policy, scope and definitions.

Effective Date

02/25/2009

516.1 Policy, scope and definitions. (a) Purpose. This Part establishes procedures for imposing monetary penalties against persons who receive or cause to be received by another person payments under the medical assistance program resulting from the commission of certain proscribed acts.

(b) The definitions in Parts 504 and 515 of this Title and the following definitions apply to this Part except as may be provided for herein:

(1) gross and flagrant violation means conduct which substantially impairs the delivery of high quality medical care, services or supplies or which has an adverse effect on the fiscal integrity of the medical assistance (MA) program.

(2) item or service means any and all medical care, services or supplies claimed to have been provided to a recipient of MA and which is listed in an itemized claim for payment.

(3) person means natural person, corporation, partnership, association, clinic, group and other entities, whether or not such person is enrolled in the MA program or is a purveyor of health care.

(4) standards of generally accepted practice means the degree of knowledge, skill and diligence possessed by, or required of, the average member of the profession or specialty which is practiced. Standards of generally accepted practice also include those practices which are accepted as effective and appropriate by the medical and scientific community of this State.

(5) standards of the MA program include but are not limited to the standards set forth in the regulations of the department.

(6) substantial number of cases means five percent or more of those cases identified in any sample of cases which were the subject of an audit or otherwise reviewed by the department and for which claims were submitted by a person for payment under the MA program.

(c) Basis for monetary penalties. The department may require the payment of a monetary penalty to the MA program by:

(1) any person who fails to comply with the standards of either the MA program or of generally accepted medical practice as defined in this section in a substantial number of cases and who receives or causes to be received by another person payment from the MA program when such person knew or had reason to know that:

(i) the payment was a result of the provision of or ordering of care, services or supplies which were medically improper, unnecessary or in excess of the documented medical needs of the person to whom they were furnished; or

(ii) the care, services or supplies were not provided as claimed; or

(iii) the person who ordered or prescribed the care, services or supplies was suspended or excluded from the MA program pursuant to Part 515 of this Title at the time the care, services or supplies were furnished; or

(iv) the care, services or supplies for which payment was received were not, in fact, provided; or

(2) any person who grossly or flagrantly violates the standards set forth in paragraph (1) of this subdivision and who received or caused to be received by another person payment from the MA program when such person knows or had reason to know that:

(i) the payment was a result of the provision of or the ordering of care, services or supplies which were medically improper, unnecessary or in excess of the documented medical needs of the person to whom they were furnished; or

(ii) the care, services or supplies were not provided as claimed; or

(iii) the person who ordered or prescribed the care, services or supplies was suspended or excluded from the MA program pursuant to Part 515 of this Title at the time the care, services or supplies were furnished; or

(iv) the care, services or supplies for which payment was received were not, in fact, provided.

Volume

VOLUME C (Title 18)

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