Or. Admin. Code § 410-120-1460

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-120-1460 - Type and Conditions of Sanction

(1) The Health Systems Division (Division) may impose mandatory Sanctions on a Provider pursuant to OAR 410-120-1400(4), in which case:

(a) The Provider shall be either Terminated or Suspended from participation in Oregon's medical assistance programs;

(b) If Suspended, the minimum duration of Suspension shall be determined by the Secretary of the Department of Health and Human Services (DHHS), under the provisions of 42 CFR Parts 420, 455, 1001, or 1002. The Authority may Suspend a Provider from participation in Oregon's medical assistance programs longer than the minimum Suspension determined by the DHHS Secretary.

(2) The Division may impose the following discretionary Sanctions on a Provider pursuant to OAR 410-120-1400(5):

(a) The Provider may be Terminated from participation in Oregon's medical assistance programs;

(b) The Provider may be Suspended from participation in Oregon's medical assistance programs for a specified length of time, or until specified conditions for reinstatement are met and approved by Division;

(c) The Division may withhold payments to a Provider;

(d) The Provider may be required to attend Provider education sessions at the expense of the Sanctioned Provider;

(e) The Division may require that payment for certain services are made only after the Division has reviewed documentation supporting the services;

(f) The Division may recover investigative and legal costs;

(g) The Division may provide for reduction of any amount otherwise due the Provider.The reduction may be up to three times the amount a Provider sought to collect from a client in violation of OAR 410-120-1280; or

(h) Any other Sanctions reasonably designed to remedy or compel future compliance with federal, state, or Division regulations.

(3) The Division shall consider the following factors in determining the Sanction(s) to be imposed:

(a) Seriousness of the offense(s);

(b) Extent of violations by the Provider;

(c) History of prior violations by the Provider;

(d) Prior imposition of Sanctions;

(e) Prior Provider education;

(f) Provider willingness to comply with program rules;

(g) Actions taken or recommended by licensing boards or a Quality Improvement Organization (QIO);

(h) Adverse impact on the health of Division clients living in the Provider's service area; and

(i) Any other relevant factors.

(4) Immediate Suspension. When a Provider fails to meet one or more of the requirements identified in this rule the Division, at its sole discretion, may immediately Suspend the Povider's Authority assigned billing number to prevent public harm or inappropriate expenditure of public funds:

(a) The Provider subject to immediate Suspension is entitled to a contested case hearing as outlined in OAR 410-120-1600 through 410-120-1700 to determine whether the Provider's authority assigned number shall be revoked;

(b) The notice requirements described in section (5) of this rule do not stop the Division's decision of immediate Suspension to prevent public harm or inappropriate expenditure of public funds. Suspension shall start immediately while the notice and contested case hearing rights are exercised.

(5) If the Authority decides to Sanction a Provider, the Division shall notify the Provider of the intent to Sanction by certified mail, personal delivery service or other traceable services such as email with delivery and read receipt. Notices sent certified mail shall be sent to the "mail-to" address on file for the Provider at the time of Sanction. Notices sent via secure email shall be sent to the Providers email if on file or the most current contact on file for the Provider a time of Sanction. The notice of immediate or proposed Sanction shall identify:

(a) The factual basis used to determine the alleged deficiencies;

(b) Explanation of actions expected of the Provider;

(c) Explanation of subsequent actions the Division intends to take;

(d) The Provider's right to dispute the Division's allegations, and submit evidence to support the Provider's position; and

(e) The Provider's right to appeal Division's proposed actions pursuant to OARs 410-120-1560 through 410-120-1700.

(6) If the Division makes a final decision to Sanction a Provider, the Division shall notify the Provider in writing at least 15 days before the effective date of action, except in the case of immediate Suspension to avoid public harm or inappropriate expenditure of funds.

(7) The Provider may appeal the Division's immediate or proposed Sanction(s) or other action(s) the Authority intends to take, including but not limited to the following list. The Provider must appeal these actions separately from any appeal of audit findings and overpayments:

(a) Termination or Suspension from participation in the Medicaid-funded medical assistance programs;

(b) Termination or Suspension from participation in the Division's state-funded programs;

(c) Revocation of the Provider's Division assigned Provider number.

(8) Other provisions:

(a) When a Provider has been Sanctioned, all other Provider entities in which the Provider has ownership (five percent or greater) or control of, may also be Sanctioned;

(b) When a Provider has been Sanctioned, the Division may notify the applicable professional society, board of registration or licensure, federal or state agencies, Oregon managed care entities, and the National Practitioner Data Base of the findings and the Sanctions imposed;

(c) At the discretion of the Division, Providers who have previously been Terminated or Suspended may or may not be re-enrolled as Division Providers;

(d) Nothing in this rule prevents the Authority from simultaneously seeking monetary recovery and imposing Sanctions against the Provider;

(e) If the Division discovers continued improper billing practices from a Provider who, after having been previously warned in writing by the Division or the Department of Justice about improper billing practices and has had an opportunity for a contested case hearing, that Provider will be liable to the Division for up to triple the amount of the Division's established overpayment received as a result of such violation.

Or. Admin. Code § 410-120-1460

PWC 683, f. 7-19-74, ef. 8-11-74; PWC 803(Temp), f. & ef. 7-1-76; PWC 812, f. & ef. 10-1-76; AFS 5-1981, f. 1-23-81, ef. 3-1-81; Renumbered from 461-013-0050, AFS 47-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 117-1982, f. 12-30-82, ef. 1-1-83; AFS 42-1983, f. 9-2-83, ef. 10-1-83; AFS 24-1985, f. 4-24-85, cert. ef. 6-1-85; AFS 33-1986, f. 4-11-86, ef. 6-1-86; HR 2-1990, f. 2-12-90, cert. ef. 3-1-90, Renumbered from 461-013-0095 & 461-013-0140; HR 19-1990, f. & cert. ef. 7-9-90; HR 41-1991, f. & cert. ef. 10-1-91; HR 32-1993, f. & cert. ef. 11-1-93, Renumbered from 410-120-0260 & 410-120-0660; HR 5-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 35-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 39-2005, f. 9-2-05, cert. ef. 10-1-05; OMAP 15-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 81-2023, amend filed 10/18/2023, effective 10/18/2023

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.025 & 414.065