Section 7 AAC 105.400 - Grounds for sanctioning providersThe department may impose sanctions for one or more of the following reasons:
(1) presenting or causing to be presented for payment any false or fraudulent claim for services or supplies;(2) 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 a rate established by the department or the provider's usual and customary charges;(3) submitting or causing to be submitted false information for the purpose of meeting prior authorization requirements;(4) failing to disclose or make available to the department records of services provided to Medicaid recipients and records of payments made for them;(5) failing to provide and maintain quality services to Medicaid recipients within accepted medical community standards as adjudged by a body of professional peers equivalently licensed to practice in this state;(6) engaging in a course of conduct or performing an act the department considers deceptive or abusive of the Medicaid program or continuing that conduct following notification that it should cease;(7) breaching the terms of the Medicaid provider agreement or failure to comply with the terms of the provider certification on the Medicaid claims form;(8) overusing the Medicaid program by inducing, or otherwise causing, a recipient to receive services or supplies not required or requested by the recipient;(9) rebating or accepting a fee or portion of a fee or charge for a Medicaid recipient referral;(10) violating any provision of AS 47.07 or any regulation adopted under it;(11) submitting a false or fraudulent application for provider status;(12) violating any law or code of ethics governing the conduct of relevant occupations, professions, or regulated industries;(13) being convicted of a criminal offense relating to performance of a provider agreement with the state or found liable for a negligent act resulting in death or injury to a recipient;(14) failing to meet standards required by state or federal law for participation, including licensure;(15) being excluded from the Medicare program because of fraudulent or abusive practices;(16) following a documented practice of charging recipients for Medicaid services in an amount above the payment made by the department for that Medicaid service;(17) refusing to execute a new provider agreement when requested to do so;(18) failing to correct deficiencies in provider operations after receiving written notice of these deficiencies from the department;(19) being formally reprimanded or censured by an association of the provider's peers for unethical practices;(20) being suspended or terminated from participation in another governmental medical program such as worker's compensation under AS 23.30, vocational rehabilitation services under AS 23.15.010- 23.15.210, and Medicare;(21) failing to repay or make arrangements for repaying (A) an identified overpayment or otherwise erroneous Medicaid payment under 7 AAC 105 - 7 AAC 160; or(B) an electronic health record incentive payment if the department requires repayment under 7 AAC 165.050(d) (2);(22) dispensing a lesser quantity of a prescription drug than that prescribed in order to receive multiple dispensing fees for one prescription, unless the prescription drug provider is reducing the prescribed amount in order to dispense no more than a 30-day supply;(23) billing for a prescription drug other than the drug dispensed;(24) billing for an amount in excess of the normal charge to the typical walk-in, cash-paying customer;(25) billing for a prescription refill that was not authorized by the prescriber;(26) falsely submitting a bill specifying that a prescriber required a specific brand name prescription drug rather than a less expensive generic prescription drug that is equivalent;(27) supplying false information on a dispensing fee or drug cost survey initiated by the department in order to establish or revise prescription drug payment rates;(28) failing to submit business records, medical records, or other information required by the department for the administration of the Medicaid program;(29) being convicted of, found not guilty by reason of insanity for, or adjudicated a delinquent for a crime identified as a barrier crime under 7 AAC 10.900 - 7 AAC 10.990;(30) failing to comply with the requirements of AS 47.05.300 - 47.05.390 and 7 AAC 10.900 - 7 AAC 10.990 (barrier crimes and conditions; background checks);(31) failing to remove from contact with a recipient an employee or agent who is impaired by being under the influence of alcohol or drugs while providing services to a recipient or whose use of alcohol or drugs interferes with work performance or recipient safety;(32) violating, or knowingly allowing an employee to violate, state or federal laws regulating prescription drugs and controlled substances, including forging prescriptions and unlawfully distributing a prescription drug or controlled substance;(33) failing to report to the department facts known to the provider or a provider's employee regarding the incompetent or illegal practice or conduct of a personal care assistant in connection with personal care services provided under 7 AAC 125.010 - 7 AAC 125.199;(34) submitting or causing to be submitted false information under 7 AAC 125.090;(35) failing to investigate and impose a sanction upon an employee or agent who knowingly submitted false information under 7 AAC 125.090;(36) failing to make available to the department all records of services provided to a recipient and the payments made for those services;(37) performing, or allowing an employee to perform, a service that is beyond that individual's competence or professional training;(38) failing to perform an act that is within an individual's competence and training that is necessary to prevent harm or an increase in the risk of harm to a recipient;(39) violating the disclosure of information provisions of 7 AAC 37.010 - 7 AAC 37.130;(40) discriminating, or allowing an employee to discriminate, on the basis of race, religion, color, national origin, ancestry, or sex in the provision of care to a recipient;(41) failing to maintain for each recipient, as required under 7 AAC 105.230 or another provision of 7 AAC 105 - 7 AAC 160, a contemporaneous and accurate record of the services provided;(42) for a health care professional licensed in a jurisdiction, acting or failing to act in a way that would constitute grounds for denial, suspension, or revocation of that individual's occupational license.Eff. 2/1/2010, Register 193; am 6/1/2011, Register 198; am 6/29/2017,Register 222, July 2017; am 6/7/2018,Register 226, July 2018Authority:AS 47.05.010
AS 47.05.300
AS 47.05.310
AS 47.05.320
AS 47.05.330
AS 47.05.340
AS 47.07.030
AS 47.07.040