Section 405 IAC 1-1.4-6 - Provider exclusionsAuthority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-21.5-3-6; IC 4-21.5-3-7; IC 4-21.5-4; IC 12-15-1-22; IC 35-48-1-9
Sec. 6.
(a) The following definitions apply throughout this section: (1) "Business relationship" means an entity or individual that meets one (1) or more of the following: (A) Has a direct or indirect ownership interest of five percent (5%) or more in the provider.(B) Is the owner of a whole or part interest in any mortgage, deed or trust, note or other obligation secured (in whole or in part) by the provider or any of the property assets thereof, in which whole or part interest is equal to or exceeds five percent (5%) of the total property and assets of the provider.(C) Is an officer or director of the provider, if the provider is organized as a partnership.(D) Is an agent of the provider.(E) Is a managing employee who is:(iii) an administrator; or(iv) a director; who exercises operational or managerial control over the provider or part thereof, or directly or indirectly conducts the day-to-day operations of the provider or part thereof.
(2) "Conviction" means any of the following: (A) A judgment has been entered against the individual or entity by a federal, state, or local court, regardless of whether there is an appeal pending or whether the judgment of conviction or other record relating to criminal conduct has been expunged.(B) A finding of guilt against the individual or entity by a federal, state, or local court.(C) A plea of guilty or nolo contendere by the individual or entity has been accepted by a federal, state, or local court.(D) The individual or entity has entered into participation in a first offender, deferred adjudication, or other arrangement or program where judgment of conviction has been withheld.(3) "Failure to grant immediate access" means the failure to grant access at the time of a reasonable request. The office shall deem a provider's failure to appear at the site requested to be a failure under this definition.(4) "Indirect ownership interest" means an ownership interest through any other entities that ultimately have an ownership interest in the entity at issue.(5) "Ownership interest" means an interest in either: (A) the capital, stock, or profits of the entity; or(B) any mortgage, deed, trust or note, or other obligation secured in whole or in part by the property or assets of the entity.(6) "Reasonable request" means a written request made by a properly identified agent of: (B) a state survey agency;(E) another authorized entity; during hours that the facility is open for business within a sufficient amount of time for the provider to comply.
(b) The office may exclude a provider from participation in Medicaid for the time period provided in subsection (c) for the following reasons: (1) For any reason outlined in 42 CFR 1002.3.(2) The provider has been convicted of a misdemeanor in a federal or state court relating to: (D) breach of fiduciary responsibility; or(E) other financial misconduct; in connection with the delivery of any health care program, operated by, or financed in whole or in part by, any federal, state, or local government agency.
(3) The provider has been convicted, under federal or state law, in connection with the interference or obstruction of any investigation into criminal conduct or a credible allegation of fraud.(4) A provider has been convicted under state law for the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance, as defined under IC 35-48-1-9.(5) A provider has either: (A) had its license to provide health care revoked or suspended by any state licensing authority, or has otherwise lost such license, including the right to apply for or renew such license, for reasons bearing on the provider's professional competence, professional performance, or financial integrity; or(B) surrendered the license while a formal disciplinary proceeding concerning the provider's competence, professional performance, or financial integrity was pending before a state licensing authority.(6) The provider was suspended, excluded, or otherwise sanctioned under: (A) any federal program involving the provision of health care;(C) any state health care program; for reasons bearing on the individual or entity's professional performance, professional competence, or financial integrity.
(7) The office determines that a provider has either: (A) knowingly submitted claims or requests for payments under Medicaid containing charges or costs for items or services that are greater than the provider's usual and customary charges or costs for such items or services;(B) knowingly furnished to patients, whether or not covered by Medicare or Medicaid, any items or services in excess of the patient's needs, or of a quality that fails to meet professionally recognized standards of health care;(C) knowingly submitted false claims, statements, or documents; or(D) knowingly concealed material facts.(8) A provider that has violated one (1) of the following: (9) A provider who has a business relationship with an individual who has a conviction for any of the following: (A) Neglect or abuse of patients in connection with the delivery of a health care item or service.(B) A felony relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct relating to the delivery or provision of an item or service under Medicaid.(C) A felony relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance relating to the delivery or provision of an item or service in connection with Medicaid.(D) Other misconduct related to the delivery or provision of an item or service under Medicaid.(10) A provider who has a business relationship with an individual who has had civil monetary penalties or assessments imposed under 42 U.S.C. 1320a-7a.(11) A provider who has a business relationship with an individual who has been excluded from participation in Medicare or any state health care programs.(12) A provider who fails to fully, accurately, or completely make the disclosures required under 42 CFR 455 Part B.(13) A provider who furnishes items or services for which payment may be made under Medicare or Medicaid and: (A) fails to provide such information as is necessary to determine whether such payments are or were due and the amounts thereof; or(B) has refused to permit such examination and duplication of its records as may be necessary to verify such information.(14) Failure to grant immediate access, upon reasonable request, to any of the following: (A) The state survey agency, or other authorized entity for the purpose of making any of the determinations provided in 42 CFR 1001.1301(a)(1).(B) ISDH for purposes of conducting reviews and surveys of: (ii) nursing facilities; or(iii) providers of home and community care and community care settings.(C) The IMFCU for purposes of conducting its activities.(D) The office for purposes of conducting any of the following: (iii) A site visit pursuant to IC 12-15-1-22 and 42 CFR 455.432.(iv) Any other action permitted by state or federal law.(c) The length of a provider's exclusion for the Indiana Medicaid program for any reason specified under this rule shall be three (3) years following the date of exclusion unless: (1) federal or state law requires a longer or shorter exclusionary period;(2) the provider has been permanently excluded from participating as a provider;(3) the provider enters into an agreement to accept a longer period or permanent exclusion from Medicaid;(4) the office determines that a mitigating factor outlined in subsection (d) justifies a lesser sanction period;(5) the provider's license remains in a revoked or suspended status;(6) the state licensing agency reinstates the provider's revoked or suspended license before the end of the three (3) year period;(7) the circumstances concerning the provider's refusal to grant immediate access under subsection (b)(12) and its impact on Medicaid, beneficiaries, or the public warrant a different exclusion period; or(8) the office determines that a longer or shorter exclusion period is more appropriate under subsection (d).(d) When permissible, the office, when assessing an exclusion period other than three (3) years may consider the following:(1) Nature of the offense.(2) Sentence imposed by a court.(3) Provider's criminal history.(4) Provider's cooperation federal or state officials in the investigation.(5) Impact of the provider's misconduct on the Indiana Medicaid program.(6) Provider's history of noncompliance with federal or state officials.(7) Needs of the Indiana Medicaid program.(e) The sanction period shall begin fifteen (15) days from the date the office mails notice to the provider of the grounds for the exclusion.(f) A provider excluded under this section may reapply for enrollment in order to again participate in Medicaid. The provider may not request to be reenrolled until after the exclusion period has passed. The office may grant an application for reenrollment only if it is reasonably certain that the types of actions that formed the basis for the original exclusion have not recurred and will not recur. In making this determination, the office shall consider the following: (1) The conduct of the individual or entity occurring prior to the date of the notice of exclusion, if not known to the agency at the time of the exclusion.(2) The conduct of the individual or entity after the date of the notice of exclusion.(3) Whether all fines, and all debts due and owing, including overpayments to any federal, state, or local government that relate to Medicaid or any of the state health care programs, have been paid, or satisfactory arrangements have been made, that fulfill these obligations. A provider reinstated under this section shall be considered a high risk provider for purposes of 42 CFR 455.450 and IC 12-15-1-22.
(g) A provider may appeal the office's determination to impose an exclusion or to deny its request for reinstatement in accordance with the appeal procedures in section 11 of this rule and IC 4-21.5.Office of the Secretary of Family and Social Services; 405 IAC 1-1.4-6; filed 12/21/2018, 3:17 p.m.: 20190116-IR-405180251FRAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA