441—79.2 (249A) Sanctions against provider of care. The department reserves the right to impose sanctions against any practitioner or provider of care who has violated the requirements for participation in the medical assistance program.
	 79.2(1) Definitions.
“Affiliates” means persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another.
“Iowa Medicaid enterprise” means the entity comprised of department staff and contractors responsible for the management and reimbursement of Medicaid services.
“Person” means any natural person, company, firm, association, corporation, or other legal entity.
“Probation” means a specified period of conditional participation in the medical assistance program.
“Provider” means an individual, firm, corporation, association, or institution which is providing or has been approved to provide medical assistance to a recipient pursuant to the state medical assistance program.
“Suspension from participation” means an exclusion from participation for a specified period of time.
“Suspension of payments” means the withholding of all payments due a provider until the resolution of the matter in dispute between the provider and the department.
“Termination from participation” means a permanent exclusion from participation in the medical assistance program.
“Withholding of payments” means a reduction or adjustment of the amounts paid to a provider on pending and subsequently submitted bills for purposes of offsetting overpayments previously made to the provider.
	 79.2(2) Grounds for sanctioning providers. Sanctions may be imposed by the department against a provider for any one or more of the following reasons:
	  a.   	 Presenting or causing to be presented for payment any false or fraudulent claim for services or merchandise.
	  b.   	 Submitting or causing to be submitted false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled, including charges in excess of usual and customary charges.
	  c.   	 Submitting or causing to be submitted false information for the purpose of meeting prior authorization requirements.
	  d.   	 Failure to disclose or make available to the department or its authorized agent, records of services provided to medical assistance recipients and records of payments made for those services.
	  e.   	 Failure to provide and maintain the quality of services to medical assistance recipients within accepted medical community standards as adjudged by professional peers.
	  f.   	 Engaging in a course of conduct or performing an act which is in violation of state or federal regulations of the medical assistance program, or continuing that conduct following notification that it should cease.
	  g.   	 Failure to comply with the terms of the provider certification on each medical assistance check endorsement.
	  h.   	 Overutilization of the medical assistance program by inducing, furnishing or otherwise causing the recipient to receive services or merchandise not required or requested by the recipient.
	  i.   	 Rebating or accepting a fee or portion of a fee or a charge for medical assistance patient referral.
	  j.   	 Violating any provision of Iowa Code chapter 249A, or any rule promulgated pursuant thereto.
	  k.   	 Submission of a false or fraudulent application for provider status under the medical assistance program.
	  l.   	 Violations of any laws, regulations, or code of ethics governing the conduct of occupations or professions or regulated industries.
	  m.   	 Conviction of a criminal offense relating to performance of a provider agreement with the state or for negligent practice resulting in death or injury to patients.
	  n.   	 Failure to meet standards required by state or federal law for participation, for example, licensure.
	  o.   	 Exclusion from Medicare because of fraudulent or abusive practices.
	  p.   	 Documented practice of charging recipients for covered services over and above that paid for by the department, except as authorized by law.
	  q.   	 Failure to correct deficiencies in provider operations after receiving notice of these deficiencies from the department.
	  r.   	 Formal reprimand or censure by an association of the provider’s peers for unethical practices.
	  s.   	 Suspension or termination from participation in another governmental medical program such as workers’ compensation, crippled children’s services, rehabilitation services or Medicare.
	  t.   	 Indictment for fraudulent billing practices, or negligent practice resulting in death or injury to the provider’s patients.
	 79.2(3) Sanctions. The following sanctions may be imposed on providers based on the grounds specified in 79.2(2).
	  a.   	 A term of probation for participation in the medical assistance program.
	  b.   	 Termination from participation in the medical assistance program.
	  c.   	 Suspension from participation in the medical assistance program. This includes when the department is notified by the Centers for Medicare and Medicaid Services, Department of Health and Human Services, that a practitioner has been suspended from participation under the Medicare program. These practitioners shall be suspended from participation in the medical assistance program effective on the date established by the Centers for Medicare and Medicaid Services and at least for the period of time of the Medicare suspension.
	  d.   	 Suspension or withholding of payments to provider.
	  e.   	 Referral to peer review.
	  f.   	 Prior authorization of services.
	  g.   	 One hundred percent review of the provider’s claims prior to payment.
	  h.   	 Referral to the state licensing board for investigation.
	  i.   	 Referral to appropriate federal or state legal authorities for investigation and prosecution under applicable federal or state laws.
	  j.   	 Providers with a total Medicaid credit balance of more than $500 for more than 60 consecutive days without repaying or reaching written agreement to repay the balance shall be charged interest at 10 percent per year on each overpayment. The interest shall begin to accrue retroactively to the first full month that the provider had a credit balance over $500.
Nursing facilities shall make repayment or reach agreement with the division of medical services. All other providers shall make repayment or reach agreement with the Iowa Medicaid enterprise. Overpayments and interest charged may be withheld from future payments to the provider.
	 79.2(4) Imposition and extent of sanction.
	  a.   	 The decision on the sanction to be imposed shall be the commissioner’s or designated representative’s except in the case of a provider terminated from the Medicare program.
	  b.   	 The following factors shall be considered in determining the sanction or sanctions to be imposed:
	 (1) 	 Seriousness of the offense.
	 (2) 	 Extent of violations.
	 (3) 	 History of prior violations.
	 (4) 	 Prior imposition of sanctions.
	 (5) 	 Prior provision of provider education.
	 (6) 	 Provider willingness to obey program rules.
	 (7) 	 Whether a lesser sanction will be sufficient to remedy the problem.
	 (8) 	 Actions taken or recommended by peer review groups or licensing boards.
	 79.2(5) Scope of sanction.
	  a.   	 The sanction may be applied to all known affiliates of a provider, provided that each decision to include an affiliate is made on a case-by-case basis after giving due regard to all relevant facts and circumstances. The violation, failure, or inadequacy of performance may be imputed to a person with whom the violator is affiliated where the conduct was accomplished in the course of official duty or was effectuated with the knowledge or approval of that person.
	  b.   	 Suspension or termination from participation shall preclude the provider from submitting claims for payment, whether personally or through claims submitted by any clinic, group, corporation, or other association, for any services or supplies except for those services provided before the suspension or termination.
	  c.   	 No clinic, group, corporation, or other association which is the provider of services shall submit claims for payment for any services or supplies provided by a person within the organization who has been suspended or terminated from participation in the medical assistance program except for those services provided before the suspension or termination.
	  d.   	 When the provisions of paragraph 79.2(5)“c” are violated by a provider of services which is a clinic, group, corporation, or other association, the department may suspend or terminate the organization, or any other individual person within the organization who is responsible for the violation.
	 79.2(6) Notice of sanction. When a provider has been sanctioned, the department shall notify as appropriate the applicable professional society, board of registration or licensure, and federal or state agencies of the findings made and the sanctions imposed.
	 79.2(7) Notice of violation. Should the department have information that indicates that a provider may have submitted bills or has been practicing in a manner inconsistent with the program requirements, or may have received payment for which the provider may not be properly entitled, the department shall notify the provider of the discrepancies noted. Notification shall set forth:
	  a.   	 The nature of the discrepancies or violations,
	  b.   	 The known dollar value of the discrepancies or violations,
	  c.   	 The method of computing the dollar value,
	  d.   	 Notification of further actions to be taken or sanctions to be imposed by the department, and
	  e.   	 Notification of any actions required of the provider. The provider shall have 15 days subsequent to the date of the notice prior to the department action to show cause why the action should not be taken.
	 79.2(8) Suspension or withholding of payments pending a final determination. Where the department has notified a provider of a violation pursuant to 79.2(7) or an overpayment, the department may withhold payments on pending and subsequently received claims in an amount reasonably calculated to approximate the amounts in question or may suspend payment pending a final determination. Where the department intends to withhold or suspend payments it shall notify the provider in writing.
This rule is intended to implement Iowa Code section 249A.4.