Sanctions

PURPOSE: This rule establishes the violations for which providers and clients will be penalized and those actions which will be taken against them. (1) Sanctions will be imposed by Crippled Children’s Service (CCS) against a provider for any one (1) or more of the following reasons: (A) The provider knowingly and willfully makes or causes to be made any false statement or misrepresentation of a material fact by presenting or causing to be presented for payment under CCS any false or fraudulent claim for services or merchandise; submitting or causing to be submitted false information for the purpose of obtaining greater compensation than that which the provider is legally entitled; submitting or causing to be submitted false information for the purpose of meeting prior approval status; or submitting a false or fraudulent application for provider status; (B) The provider fails to provide and maintain quality services which meet professionally recognized standards of care; (C) The provider breaks the terms of the provider agreement or fails to comply with the terms of the provider certification on the CCS claim form; (D) The provider is convicted of a criminal offense relating to performance of a provider agreement with the state or for negligent or abusive practice resulting in the death or injury of a client; (E) The provider fails to meet licensure or certification standards for participation as a given type of provider; (F) The provider solicits, charges or receives payments from recipients for services for which the provider has billed CCS; (G) The provider is suspended or terminated from participation in another governmental medical program such as, but not limited to, Workers’ Compensation, Medicaid and Medicare; (H) The provider is indicted for fraudulent billing practices or for negligent practice resulting in physical, emotional or psychological injury or death to the provider’s client; or (I) The provider fails to repay or to make arrangements for the repayment of identified overpayments or otherwise erroneous payments. (2) One (1) or more of the following sanctions may be invoked against a provider for any violation listed in section (1) of this rule: termination from participation in CCS; suspension from participation in CCS; suspension or withholding of payments; or referral for investigation to the State Board of Registration for the Healing Arts or other appropriate state licensing agency. (3) A client may be dismissed or an application cancelled for any of the following reasons: financial ineligibility; medical ineligibility; death of registrant; failure to keep scheduled appointments; failure to reply to CCS correspondence; residency established out-of-state; return appointment more than twelve (12) months away; no treatment recommended; unable to locate; age twenty-one (21) reached; failure to supply requested information; unwillingness to follow medical recommendations; medical recommendations indicate care needed is below current acceptable minimum to meet eligibility criteria for the diagnosis; or failure to properly use thirdparty coverage benefits. (4) In cases where CCS intends to discontinue, terminate, suspend or reduce benefits to clients, providers or applicants, the program must give written notice that the proposed action will occur no sooner than fourteen (14) calendar days after the notice is dated. The notice must include a statement of what action the program intends to take; the reasons for the intended action; and a statement of the right to appeal. Further information is available by contacting the nearest district or subdistrict office or the CCS central office. (5) An opportunity for a hearing is granted upon request to—an applicant whose application is denied; a client who is aggrieved by any CCS decision resulting in suspension, reduction, discontinuance or termination of benefits; or a provider who is aggrieved by any program decision resulting in suspension, reduction, discontinuance or termination of benefits. (A) A hearing shall be conducted at a reasonable time, date and place. The notice of the time, date and place of a hearing shall be mailed to the requesting applicant, client or provider at least twenty (20) days prior to the hearing. (B) An officer appointed by the director of the Department of Health shall preside at the hearing. The officer shall not have been involved in the initial determination of the action in question. The hearing officer shall prepare a report consisting of a statement of issues, findings of fact, conclusions and recommendations. (C) The appellant shall have adequate opportunity to record the hearing proceedings, examine the contents of his/her case file, bring witnesses, establish all pertinent facts, advance arguments without undue interference and question or refute any testimony or evidence. (D) The final decision shall be made by the director of the Department of Health, based upon the evidence and other material introduced at the hearing and the hearing officer’s report. This decision shall be mailed to the appellant within ninety (90) calendar days after the hearing date. (6) Any person who has exhausted all administrative remedies provided by law and sections (4) and (5) and subsections (5)(A) and (B) of this rule and who is aggrieved by a final decision in a contested case, whether this decision is affirmative or negative, shall be entitled to judicial review as provided in sections 536.100–536.140, RSMo 1986. AUTHORITY: sections 192.005.2 and 201.060, RSMo 1986.* This rule was previously filed 13 CSR 50-160.080. Emergency rule filed Dec. 12, 1984, effective Dec. 22, 1984, expired April 20, 1985. Original rule filed Dec. 12, 1984, effective April 11, 1985. Amended: Filed June 2, 1987, effective Aug. 13, 1987. *Original authority: 192.005, RSMo 1985 and 201.060, RSMo 1959.