| (a) The OIG may terminate the enrollment or cancel
the contract of a person by debarment, suspension, revocation, or
other deactivation of participation, as appropriate. The OIG may terminate
or cancel a person's enrollment or contract if it determines that
the person committed an act for which a person is subject to administrative
actions or sanctions.
(b) When the OIG establishes the following by prima
facie evidence, the OIG must terminate or cancel the enrollment or
contract from the Medicaid program or any other HHS program of:
(1) a provider or any person with an ownership interest
in the provider has been convicted of a criminal offense related to
that person's involvement with the Medicare, Medicaid, or CHIP program
in the last ten years;
(2) a provider that is terminated or revoked for cause,
excluded, or debarred under Title XVIII of the Social Security Act
or under the Medicaid program or CHIP program of any other state;
(3) a provider that fails to permit access to any and
all provider locations for unannounced or announced on-site inspections
required during the provider screening process as provided by rule;
(4) a provider when any person with an ownership or
control interest or who is an agent or managing employee of the provider
fails to submit timely and accurate information, including fingerprints
if required by CMS or state rule, and cooperate with any and all screening
methods required during the provider screening process as provided
by rule, statute, rule, or regulation;
(5) a provider that fails to submit sets of fingerprints
in a form and manner to be provided by rule;
(6) a person that fails to repay overpayments under
the Medicaid program or CHIP;
(7) a person that owns, controls, manages, or is otherwise
affiliated with and has financial, managerial, or administrative influence
over a provider who has been suspended or prohibited from participating
in Medicare, Medicaid, or CHIP;
(8) a provider that fails to identify or disclose in
the provider screening process for any HHS program:
(A) all persons with a direct or indirect ownership
or control interest, as defined by 42 C.F.R. §455.101;
(B) all information required to be disclosed in accordance
with 42 C.F.R. §1001.1101, 42 C.F.R. chapter 455, or other by
statute, rule, or regulation; or
(C) all agents or subcontractors of the provider:
(i) if the provider or a person with an ownership interest
in the provider has an ownership interest in the agent or subcontractor;
or
(ii) if the provider engages in a business transaction
with the agent or subcontractor that meets the criteria specified
by 42 C.F.R. §455.105; or
(9) a provider that has been excluded or debarred from
participation in a state or federally funded health care program as
a result of:
(A) a criminal conviction or finding of civil or administrative
liability for committing a fraudulent act, theft, embezzlement, or
other financial misconduct under a state or federally funded health
care program; or
(B) a criminal conviction for committing an act under
a state or federally funded health care program that caused bodily
injury to:
(i) a person who is 65 years of age or older;
(ii) a person with a disability; or
(iii) a person under 18 years of age.
(c) When the OIG establishes the following by prima
facie evidence, the OIG may terminate or cancel the enrollment or
contract from Medicaid, CHIP, or any other HHS program of:
(1) a provider if a criminal history check reveals
a prior criminal conviction;
(2) a provider that has failed to bill for medical
assistance or refer clients for medical assistance within a 12-month
period;
(3) a provider that has been excluded or debarred from
participation in any federally funded health care program not described
in subsection (b)(2) of this section;
(4) a provider that has falsified any information on
its application for enrollment as determined by the OIG;
(5) a provider whose identity on an application for
enrollment cannot be verified by the OIG;
(6) a person that commits a program violation;
(7) a person that is affiliated with a person who commits
a program violation;
(8) a person that commits an act for which sanctions,
damages, penalties, or liability could be or are assessed by the OIG;
or
(9) a person whose contract may be cancelled for any
other reason specified by statute or regulation.
(d) Exceptions.
(1) The OIG need not terminate participation if the
person or provider voluntarily resigned from participation under Title
XVIII of the Social Security Act or under the Medicaid program or
CHIP program of any other state, and the resignation was not in lieu
of or to avoid exclusion, termination, or any other sanction.
(2) The OIG need not terminate participation based
on a conviction described in subsection (b)(1) of this section, a
termination described in subsection (b)(2) of this section, or a failure
to allow access described in subsection (b)(3) of this section if
the OIG:
(A) determines that termination is not in the best
interests of the Medicaid program; and
(B) documents that determination and the rationale
in writing.
(e) Notice. Notice of termination includes:
(1) a description of the termination;
(2) the basis for the termination;
(3) the effect of the termination;
(4) the duration of the termination;
(5) whether re-enrollment will be required after the
period of termination; and
(6) a statement of the person's right to request an
informal resolution meeting or an administrative hearing regarding
the imposition of the termination unless the termination is required
under 42 C.F.R. §455.416.
(f) Due process.
(1) After receiving a notice of termination, a person
has a right to the informal resolution process in accordance with §371.1613
of this subchapter (relating to Informal Resolution Process) unless
the termination is required under 42 C.F.R. §455.416.
(2) A person may request an administrative hearing
after receipt of a final notice of termination in accordance with §371.1615
of this subchapter (relating to Appeals) unless the termination is
required under 42 C.F.R. §455.416. The OIG must receive the written
request for a hearing no later than the 15 days after the date the
person receives the notice.
(g) Scope and effect of termination.
(1) A person's enrollment agreement or contract is
nullified on the effective date of the termination.
(2) Once a person's enrollment agreement or contract
is terminated or cancelled, no items or services furnished are reimbursed
by the Medicaid or other HHS program during the period of termination
or cancellation.
(3) Following termination, the person must re-enroll
in order to participate as a provider in the Medicaid or other HHS
program, if the person was terminated for any grounds in subsection
(b) or (c)(1) - (3) of this section. Re-enrollment requires the provider
to meet all applicable screening requirements, including the payment
of any application fees.
(4) A person may be terminated from participation in
the Medicare program and in the Medicaid program of every other state
as a result of the termination.
(5) If, after the effective date of the termination
or cancellation, a person submits or causes to be submitted claims
for services or items furnished within the period of termination or
cancellation, the person may be liable to repay any submitted claims
or subject to civil monetary penalty liability under §1128A(a)(1)(D),
and criminal liability under §1128B(a)(3) of the Social Security
Act in addition to sanctions or penalties by the OIG.
(6) The termination or cancellation may, as determined
by the OIG, become immediately effective and final on the date reflected
on the notice of cancellation in the following circumstances:
(A) the person subject to termination or cancellation
may be placing at risk the health or safety of persons receiving services
under Medicaid;
(B) the person who is subject to termination or cancellation
fails:
(i) to grant immediate access to the OIG or to a requesting
agency upon reasonable request;
(ii) to allow the OIG or a requesting agency to conduct
any duties that are necessary to the performance of their official
functions; or
Cont'd... |
