10A NCAC 22F .0301. DEFINITION OF PROVIDER ABUSE

10 NCAC 22f .0301           DEFINITION OF PROVIDER ABUSE

Provider abuse includes any incidents, services, or practices inconsistent with accepted fiscal or medical practices which cause financial loss to the Medicaid program or its beneficiaries, or which are not reasonable or which are not necessary including, for example, the following:

(1)           Overutilization of medical and health care and services.

(2)           Separate billing for care and services that are:

(a)           part of an all‑inclusive procedure,

(b)           included in the daily per‑diem rate.

(3)           Billing for care and services that are provided by an unauthorized or unlicensed person.

(4)           Failure to provide and maintain within accepted medical standards for the community:

(a)           proper quality of care,

(b)           appropriate care and services, or

(c)           medically necessary care and services.

(5)           Breach of the terms and conditions of participation agreements, or a failure to comply with requirements of certification, or failure to comply with the provisions of the claim form.

The foregoing examples do not restrict the meaning of the general definition.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 42 C.F.R. 455, Subpart C;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984.