441—79.2 (249A) Sanctions.
	 79.2(1) Definitions.
“Affiliates” means persons having an overt or covert relationship such that any one of them directly or indirectly controls or influences or has the power to control or influence another.
“Iowa Medicaid enterprise” means the entity comprised of department staff and contractors responsible for the management and reimbursement of Medicaid services for the benefit of Medicaid members.
“Person” means any individual human being or any company, firm, association, corporation, institution, or other legal entity. “Person” includes but is not limited to a provider and any affiliate of a provider.
“Probation” means a specified period of conditional participation in the medical assistance program.
“Provider” means an individual human being, firm, corporation, association, institution, or other legal entity, which is providing or has been approved to provide medical assistance to a member 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 temporary cessation of payments due a person until the resolution of the matter in dispute between the person 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 person on pending and subsequently submitted bills for purposes of offsetting overpayments previously made to a person.
	 79.2(2) Grounds for sanctions. The department may impose sanctions against any person when appropriate. Appropriate grounds for the department to impose sanctions include, but are not limited to, the following:
	  a.   	 Presenting or causing to be presented for payment any false, intentionally misleading, or fraudulent claim for services or merchandise.
	  b.   	 Submitting or causing to be submitted false, intentionally misleading, or fraudulent information for the purpose of obtaining greater compensation than that to which the person is legally entitled, including charges in excess of usual and customary charges.
	  c.   	 Submitting or causing to be submitted false, intentionally misleading, or fraudulent information for the purpose of meeting prior authorization or level of care requirements.
	  d.   	 Upon lawful demand, failing to disclose or make available to the department, the department’s authorized agent, any law enforcement or peace officer, any agent of the department of inspections and appeals’ Medicaid fraud control unit, any agent of the auditor of state, the Iowa department of justice, any false claims investigator as defined under Iowa Code chapter 685, or any other duly authorized federal or state agent or agency records of services provided to medical assistance members or records of payments made for those services.
	  e.   	 Failing to provide or maintain quality services, or a requisite assurance of a framework of quality services to medical assistance recipients within accepted medical community standards as adjudged by professional peers if applicable. For purposes of this subrule, “quality services” means services provided in accordance with the applicable rules and regulations governing the services.
	  f.   	 Engaging in a course of conduct or performing an act which is in violation of any federal, state, or local statute, rule, regulation, or ordinance, or an applicable contractual provision, that relates to, or arises out of, any publicly or privately funded health care program, including but not limited to any state medical assistance program.
	  g.   	 Submitting a false, intentionally misleading, or fraudulent certification or statement, whether the certification or statement is explicit or implied, to the department or the department’s representative or to any other publicly or privately funded health care program.
	  h.   	 Overutilization of the medical assistance program by inducing, furnishing or otherwise causing a member to receive services or merchandise not required or requested.
	  i.   	 Violating any provision of Iowa Code chapter 249A, or any rule promulgated pursuant thereto, or violating any federal or state false claims Act, including but not limited to Iowa Code chapter 685.
	  j.   	 Submitting or causing to be submitted false, intentionally misleading, or fraudulent information in an application for provider status under the medical assistance program or any quality review or other submission required to maintain good standing in the program.
	  k.   	 Violating any law, regulation, or code of ethics governing the conduct of an occupation, profession, or other regulated business activity, when the violation relates to, or arises out of, the delivery of services under the state medical assistance program.
	  l.   	 Breaching any settlement or similar agreement with the department.
	  m.   	 Failing to meet standards required by state or federal law for participation, including but not limited to licensure.
	  n.   	 Exclusion from Medicare or any other state or federally funded medical assistance program.
	  o.   	 Except as authorized by law, charging a person for covered services over and above what the department paid or would pay or soliciting, offering, or receiving a kickback, bribe, or rebate, or accepting or rebating a fee or a charge for medical assistance or patient referral, or a portion thereof. This ground does not include the collection of a copayment or deductible if otherwise allowed by law.
	  p.   	 Failing to correct a deficiency in provider operations after receiving notice of the deficiency from the department or other federal or state agency.
	  q.   	 Formal reprimand or censure by an association of the provider’s peers or similar entity related to professional conduct.
	  r.   	 Suspension or termination for cause from participation in another program, including but not limited to workers’ compensation or any publicly or privately funded health care program.
	  s.   	 Indictment or other institution of criminal charges for, or plea of guilty or nolo contendere to, or conviction of, any crime punishable by a term of imprisonment greater than one year, any crime of violence, any controlled substance offense, or any crime involving an allegation of dishonesty or negligent practice resulting in death or injury to a provider’s patient.
	  t.   	 Violation of a condition of probation, suspension of payments, or other sanction.
	  u.   	 Loss, restriction, or lack of hospital privileges for cause.
	  v.   	 Negligent, reckless, or intentional endangerment of the health, welfare, or safety of a person.
	  w.   	 Billing for services provided by an excluded, nonenrolled, sanctioned, or otherwise ineligible provider or person.
	  x.   	 Failing to submit a self-assessment, corrective action plan, or other requirement for continued participation in the medical assistance program, or failing to repay an overpayment of medical assistance funds, in a timely manner, as set forth in a rule or other order.
	  y.   	 Attempting, aiding or abetting, conspiring, or knowingly advising or encouraging another person in the commission of one or more of the grounds specified herein.
	 79.2(3) Sanctions.
	  a.   	 The department may impose any of the following sanctions on any person:
	 (1) 	 A term of probation for participation in the medical assistance program.
	 (2) 	 Termination from participation in the medical assistance program.
	 (3) 	 Suspension from participation in the medical assistance program.
	 (4) 	 Suspension of payments in whole or in part.
	 (5) 	 Prior authorization of services.
	 (6) 	 Review of claims prior to payment.
	  b.   	 The withholding of payments or a recoupment of medical assistance funds is not, in itself, a sanction. Overpayments and interest charged may be withheld from future payments to the provider without imposing a sanction.
	  c.   	 Mandatory suspensions and terminations.
	 (1) 	 Suspension or termination from participation in the medical assistance program is mandatory when a person is suspended or terminated from participation in the Medicare program, another state’s medical assistance program, or by any licensing body. The suspension or termination from participation in the medical assistance program shall be retroactive to the date established by the Centers for Medicare and Medicaid Services or other state or body and, in the case of a suspension, must continue until at least such time as the Medicare or other state’s or body’s suspension ends.
	 (2) 	 Termination is mandatory when a person pleads guilty or nolo contendere to, or is convicted of, any crime punishable by a term of imprisonment greater than five years, any crime of violence, any controlled substance offense, or any crime involving an allegation of dishonesty. Termination is also mandatory upon entry of final judgment, in the Iowa district court or a federal district court of the United States, of liability of the person in a false claims action.
	 (3) 	 Suspension from participation is mandatory whenever a person, or an affiliate of the person, has an outstanding overpayment of medical assistance funds, as defined in Iowa Code chapter 249A.
	  d.   	 Notwithstanding any previous successful enrollment in the medical assistance program, the person’s passing of any background check by the department or any other entity, or similar prior approval for participation as a provider in the medical assistance program, in whole or in part, termination from the medical assistance program is mandatory when, in the case of a natural person, the person has within the last five years been listed on any dependent adult abuse registry, child abuse registry, or sex offender registry or, in the case of a corporation or similar entity, 5 percent or more of the corporation or similar entity is owned by a person who has within the last five years been listed on any dependent adult abuse registry, child abuse registry, or sex offender registry.
	 79.2(4) Imposition and extent of sanction.
	  a.   	 The department shall consider the totality of the circumstances in determining the sanctions to be imposed. The factors the department may consider include, but are not limited to:
	 (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 (technical assistance).
	 (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.
	  b.   	 A ground for sanction may precede enrollment in the medical assistance program, the person’s passing of a background check, or similar prior approval for participation as a provider in the medical assistance program. The mere fact of an enrollment, a person’s passing of a background check, or another approval is not relevant to the sanction decision.
	  c.   	 Upon certification from the U.S. Department of Justice or the Iowa department of justice that a provider has failed to respond to a civil investigative demand in a timely manner as set forth in Iowa Code chapter 685 and the demand itself, the department shall immediately suspend the provider from participation and suspend all payments to the provider. The suspension and payment suspension shall end upon certification that the provider has responded to the demand in full.
	 79.2(5) Scope of sanction.
	  a.   	 Suspension or termination from participation shall preclude the person from submitting claims for payment, whether personally or through claims submitted by any other person or affiliate, for any services or supplies except for those services provided before the suspension or termination.
	  b.   	 No person may submit claims for payment for any services or supplies provided by a person or affiliate who has been suspended or terminated from participation in the medical assistance program except for those services provided before the suspension or termination.
	  c.   	 When the provisions of this subrule are violated, the department may sanction any person responsible for the violation.
	 79.2(6) Notice to third parties. When a sanction is imposed, the department may notify third parties of the findings made and the sanction imposed, including but not limited to law enforcement or peace officers and federal or state agencies. The imposition of a sanction is not required before the department may notify third parties of a person’s conduct. In accordance with 42 CFR § 1002.212, the department must notify other state agencies, applicable licensing boards, the public, and Medicaid members, as provided in 42 CFR §§ 1001.2005 and 1001.2006, whenever the department initiates an exclusion under 42 CFR § 1002.210.
	 79.2(7) Notice of violation.
	  a.   	 Any order of sanction shall be in writing and include the name of the person subject to sanction, identify the ground for the sanction and its effective date, and be sent to the person’s last-known address. If the department sanctions a provider, the order of sanction shall also include the national provider identification number of the provider and be sent to the provider’s last address on file within the medical assistance program.
	  b.   	 In the case of a currently enrolled provider otherwise in good standing with all program requirements, 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. If the provider fails to do so, the sanction shall remain effective pending any subsequent appeal under 441—Chapter 7. If the provider attempts to show cause but the department determines the sanction should remain effective pending any subsequent appeal under 441—Chapter 7, the provider may seek a temporary stay of the department’s action from the director or the director’s designee by filing an application for stay with the appeals section. The director or the director’s designee shall consider the factors listed in Iowa Code section 17A.19(5)“c.”
	 79.2(8) Suspension or withholding of payments pending a final determination. Where the department has notified a provider of any sanction, overpayment, civil monetary penalty, or other adverse action, 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.
	 79.2(9) Civil monetary penalties and interest. Civil monetary penalties and interest assessed in accordance with 2013 Iowa Acts, Senate File 357, section 5 or section 11, are not allowable costs for any aspect of determining payment to a person within the medical assistance program. Under no circumstance shall the department reimburse a person for such civil monetary penalties or interest.
	 79.2(10) Report and return of identified overpayment.
	  a.   	 If a person has identified an overpayment, the person must report and return the overpayment in the form and manner set forth in this subrule.
	  b.   	 A person has identified an overpayment if the person has actual knowledge of the existence of the overpayment or acts in reckless disregard or deliberate ignorance of the existence of the overpayment.
	  c.   	 An overpayment required to be reported under 2013 Iowa Acts, Senate File 357, section 3, must be made in writing, addressed to the Program Integrity Unit of the Iowa Medicaid Enterprise, and contain all of the following:
	 (1) 	 Person’s name.
	 (2) 	 Person’s tax identification number.
	 (3) 	 How the error was discovered.
	 (4) 	 The reason for the overpayment.
	 (5) 	 Claim number(s), as appropriate.
	 (6) 	 Date(s) of service.
	 (7) 	 Member identification number(s).
	 (8) 	 National provider identification (NPI) number.
	 (9) 	 Description of the corrective action plan to ensure the error does not occur again, if applicable.
	 (10) 	 Whether the person has a corporate integrity agreement with the Office of the Inspector General (OIG) or is under the OIG Self-Disclosure Protocol or is presently under sanction by the department.
	 (11) 	 The time frame and the total amount of refund for the period during which the problem existed that caused the refund.
	 (12) 	 If a statistical sample was used to determine the overpayment amount, a description of the statistically valid methodology used to determine the overpayment.
	 (13) 	 A refund in the amount of the overpayment.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 1155C, IAB 10/30/13, effective 1/1/14]