Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 950. Grounds for sanctioning providers

7 AAC 43.950. Grounds for sanctioning providers

Sanctions may be imposed by the division for any one or more of the following reasons:

(1) presenting or causing to be presented for payment any false or fraudulent claim for services or supplies;

(2) submitting or causing to be submitted false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled, including charges in excess of a rate established by the division or the provider's usual and customary charges;

(3) submitting or causing to be submitted false information for the purpose of meeting prior authorization requirements;

(4) failing to disclose or make available to the division or its authorized agent records of services provided to medicaid recipients and records of payments made for them;

(5) failing to provide and maintain quality services to medicaid recipients within accepted medical community standards as adjudged by a body of professional peers equivalently licensed to practice in this state;

(6) engaging in a course of conduct or performing an act considered improper or abusive of the Medicaid program or continuing that conduct following notification that it should cease;

(7) breaching the terms of the Medicaid provider agreement or failure to comply with the terms of the provider certification on the Medicaid claims form;

(8) over-using the medicaid program by inducing, or otherwise causing a recipient to receive services or supplies not required or requested by the recipient;

(9) rebating or accepting a fee or portion of a fee or charge for a medicaid recipient referral;

(10) violating any provision of AS 47.07 or any regulation adopted under it;

(11) submitting a false or fraudulent application for provider status;

(12) violating any law, regulation, or code of ethics governing the conduct of occupations, professions or regulated industries;

(13) being convicted of a criminal offense relating to performance of a provider agreement with the state or to a negligent practice resulting in death or injury to a patient;

(14) failing to meet standards required by state or federal law for participation, such as licensure;

(15) being excluded from the medicare program because of fraudulent or abusive practices;

(16) following a documented practice of charging recipients for services an amount above payment made by the division;

(17) refusing to execute a new provider agreement when requested to do so;

(18) failing to correct deficiencies in provider operations after receiving written notice of these deficiencies from either the division of public assistance, the division of public health, or the division of mental health;

(19) being formally reprimanded or censured by an association of the provider's peers for unethical practices;

(20) being suspended or terminated from participation in another governmental medical program such as worker's compensation, crippled children's program, vocational rehabilitation services, and medicare;

(21) failing to repay or make arrangements for repaying identified overpayments or otherwise erroneous payment;

(22) dispensing a lesser quantity of a drug than that prescribed in order to receive multiple dispensing fees for one prescription, unless the drug provider is reducing the prescribed amount in order to dispense no more than a 30-day supply;

(23) billing for a drug other than the drug dispensed;

(24) billing for an amount in excess of the normal charge to the typical walk-in, cash-paying customer;

(25) billing for a prescription refill that was not authorized by the prescriber;

(26) falsely submitting a bill specifying that a prescriber required a specific brand name drug rather than a less expensive generic equivalent;

(27) supplying false information on a dispensing fee or drug cost survey initiated by the division of medical assistance in order to establish or revise drug reimbursement rates;

(28) failing to submit business records or other information determined by the division of medical assistance to be necessary for the administration of the Medicaid program;

(29) being convicted of, or allowing an employee to provide services reimbursed under this chapter who has been convicted of, a crime that involves contributing to the delinquency of a minor or any sex offense as defined in AS 11 or in the laws of another jurisdiction;

(30) engaging in, or failing to report, any act of abuse or neglect of a child reportable under AS 47.17.010 - 47.17.022, any harm of an elderly or disabled adult reportable under AS 47.24.010 - 47.24.120, or any other acts reportable under 7 AAC 37.050(b) , if the personal care attendant learns of the abuse or neglect in connection with work-related activities;

(31) engaging in, or threatening a recipient or a member of recipients' household with, physical, sexual, or mental abuse or coercion;

(32) failing to remove an employee from contact with a recipient when there is probable cause to believe that the employee has engaged in an act identified in (31) of this section while providing service under this chapter;

(33) exploiting a recipient for financial gain or failing to remove an employee who has exploited a recipient for financial gain;

(34) theft of medication, money, property, supplies, equipment, or other assets of a recipient or the division;

(35) failing to report a theft as described in (34) of this section;

(36) failing to remove from contact with a recipient any employee who is under the influence of alcohol or drugs while providing services to a recipient or whose use of alcohol or drugs interferes with work performance or recipient safety;

(37) violating, or knowingly allowing an employee to violate, state or federal laws regulating prescription drugs and controlled substances, including forging prescriptions and unlawfully distributing;

(38) failing to report to the division facts known to the provider or a provider's employee regarding the incompetent or illegal practice or conduct of a care provider in connection with personal care services;

(39) submitting or causing to be submitted false information under 7 AAC 43.770(a) (2);

(40) failing to investigate and sanction an employee who has knowingly falsified information under 7 AAC 43.770(a) (2);

(41) failing to make available to the division all records of services provided to a recipient and the payments made for those services;

(42) performing, or allowing an employee to perform, a service that is beyond that person's professional training;

(43) failing to perform the acts that are within a person's scope of competence and training that are necessary to prevent harm or an increase in the risk of harm to a recipient;

(44) violating the disclosure of information provisions of 7 AAC 37.010 - 7 AAC 37.130;

(45) discriminating, or allowing an employee to discriminate, on the basis of race, religion, color, national origin, ancestry, or sex in the provision of care to a recipient;

(46) failing to maintain for each recipient a contemporaneous and accurate record of the services provided;

(47) a health care professional's act or failure to act that would constitute grounds for denial, suspension, or revocation of that individual's occupational license issued under AS 08.

History: Eff. 8/18/79, Register 71; am 2/1/89, Register 109; am 6/14/89, Register 110; am 6/27/92, Register 122; readopt 8/7/96, Register 139

Authority: Chapter 120, SLA

1988

AS 47.05.010

AS 47.05.050

AS 47.07.030

AS 47.07.050

Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.950 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.