10A NCAC 22F .0602. ADMINISTRATIVE SANCTIONS AND REMEDIAL MEASURES

(a)  The following types of sanctions may be imposed, singly or in combination, by the Medicaid Agency in instances of program abuse by providers:

(1)           Warning letters for those instances of abuse that can be satisfactorily settled by issuing a warning to cease the specific abuse. The letter will state that any further violations will result in administrative or legal action initiated by the Medicaid Agency.

(2)           Suspension of a provider from further participation in the Medicaid Program for a specified period of time, provided the appropriate findings have been made and provided that this action does not deprive recipients of access to reasonable service of adequate quality.

(3)           Termination of a provider from further participation in the Medicaid Program, provided the appropriate findings have been made and provided that this action does not deprive recipients of access to reasonable services of adequate quality.

(4)           Probation whereby a provider's participation is closely monitored for a specified period of time not to exceed one year.  At the termination of the probation period the Medicaid Agency will conduct a follow-up review of the provider's Medicaid practice to ensure compliance with the Medicaid rules.  Notwithstanding his probation, a probationary provider's participation, like that of all providers, is terminable at will.

(5)           Remedial Measures to include:

(A)          placing the provider on "flag" status whereby his claims are remanded for manual review;

(B)          establishing a monitoring program not to exceed one year whereby the provider must comply with pre-established conditions of participation to allow review and evaluation of his Medicaid practice, i.e., quality of care.

(b)  The following factors are illustrative of those to be considered in determining the kind and extent of administrative sanctions to be imposed:

(1)           seriousness of the offense;

(2)           extent of violations found;

(3)           history or prior violations;

(4)           prior imposition of sanctions;

(5)           period of time provider practiced violations;

(6)           provider willingness to obey program rules;

(7)           recommendations by the investigative staff or Peer Review Committees; and

(8)           effect on health care delivery in the area.

When a provider has been administratively sanctioned, the Division shall notify the appropriate professional society, board of licensure, State Attorney General's Office, federal and state agencies, and appropriate county departments of social services of the findings made and the sanctions imposed.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455;

Eff. May 1, 1984;

Amended Eff. December 1, 1995; May 1, 1990.