Idaho Admin. Code r. 16.05.07.236

Current through August 31, 2023

Section 16.05.07.236 - CIVIL MONETARY PENALTY PERCENTAGES

The Department will determine the percentage of each penalty by the type of conduct, the frequency, and knowledge of the conduct. When more than one (1) type of conduct described in Idaho Code 56-209h(6)(a) through (i) is found per line item, the penalty percentage will be based on the most significant conduct. (3-17-22)

01.Conduct Resulting in No Overpayment. The Department determines civil monetary penalties to be assessed for the following types of conduct violations that did not result in an overpayment. (3-17-22)

a. Participant Fees. The provider collected or attempted to collect fees from participants that the provider was not entitled to collect. Violations for this type of conduct will result in a ten percent (10%) penalty. (3-17-22)

b. Minor Rule Violations. Services were provided and properly paid but violated rule, policy, or provider agreement. Minor rule violations will result in a ten percent (10%) penalty. Minor rule violations may include: (3-17-22)

i. Incorrect date spanning; (3-17-22)

ii. Failure to list required provider credentials; or (3-17-22)

iii. Failure to obtain required client signatures. (3-17-22)

c. Significant Rule Violations. Services were provided but violated rule, policy, or provider agreement. Significant rule violations will result in a fifteen percent (15%) penalty. Significant rule violations may include: (3-17-22)

i. Incomplete physician referrals; or (3-17-22)

ii. Failure to maintain documentation once valid Healthy Connections referral is obtained. (3-17-22)

02.Conduct Resulting in Overpayment. The Department determines the civil monetary penalties to be assessed for the following types of conduct violations resulting in overpayment. Civil monetary penalties will not be assessed when a provider self-reports an overpayment and the Department receives the report prior to the initiation of a Department audit. (3-17-22)

a. Significant Rule Violations. Services were provided but violated rule, policy, or provider agreement. Significant rule violations will result in a fifteen percent (15%) penalty. Significant rule violations may include: (3-17-22)

i. Billing more services than allowed; (3-17-22)

ii. Billing non-physician services as physician services; (3-17-22)

iii. Billing incorrect codes (such as Physician's Current Procedural Terminology (CPT), diagnosis, revenue, etc.) or modifiers; or (3-17-22)

iv. Inadequate documentation to support services billed. (3-17-22)

b. Significant Rule Violations Related to Participant Care. Services were provided but violated rule, policy, or provider agreement related to participant care. Significant rule violations related to participant care will result in a twenty percent (20%) penalty. Significant rule violations may include: (3-17-22)

i. Failure to obtain required Healthy Connections referrals or failure to list required core elements, such as the start and end dates on the referral; (3-17-22)

ii. No required physician or practitioner signatures; (3-17-22)

iii. No orders or inadequate orders, assessments, plans or evaluations prior to delivery of service or items; (3-17-22)

iv. Services or items provided by unqualified staff; (3-17-22)

v. Services or items provided by excluded individual; or (3-17-22)

vi. Services or items not covered by program. (3-17-22)

c. Significant Rule Violations for No Service or Refusal of Immediate Access to Documentation. Services were not provided, were not documented, or refusal to provide immediate access to documentation upon written request as required in Section 56-209h(6)(e), Idaho Code, of these rules. Violations will result in a twenty-five percent (25%) penalty. Significant rule violations may include: (3-17-22)

i. Billing and receiving payment multiple times for the same service or item; (3-17-22)

ii. No documentation; (3-17-22)

iii. Cloned documentation; (3-17-22)

iv. Service not provided; (3-17-22)

v. More units billed than provided; (3-17-22)

vi. Billing laboratory services provided by independent laboratory, unless an exception applies, such as an independent laboratory that can bill for a reference laboratory; or (3-17-22)

vii. Missing required pre-authorization. (3-17-22)

03.Penalty Enhancements. (3-17-22)

a. Error Rates. The Department determines which error rate applies by comparing the number of violations to the number of similar line items audited, or to all audited line items. Penalty percentages identified in Subsections 236.01 and 236.02 of this rule may be increased by: (3-17-22)

i. Five percent (5%) when the error percentage of audited services is greater than twenty-five percent (25%); and (3-17-22)

ii. Ten percent (10%) when the error percentage of audited services is greater than thirty-five percent (35%). (3-17-22)

b. Fraudulently or Knowingly. When the Department determines the conduct was committed fraudulently or knowingly as defined in Section 010 of these rules, the penalty percentages may be increased by fifteen percent (15%). (3-17-22)

Idaho Admin. Code r. 16.05.07.236