1.For purposes of this section:
a."Affiliate" means a person having an overt or covert relationship each with
another person in a manner that one person directly or indirectly controls or has
the power to control another.
b."Provider" means any individual or entity furnishing Medicaid services under a
provider agreement with the department.
2.A provider, an affiliate of a provider, or any combination of provider and affiliates, is
liable to the department for up to twenty-five percent of the amount the department
was induced to pay as a result of each act of fraud or abuse. This sanction is in
addition to the applicable rules established by the department.
3.A provider, an affiliate of a provider, or any combination of provider and affiliates, is
liable to the department for up to fiv
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1. For purposes of this section:
a. "Affiliate" means a person having an overt or covert relationship each with
another person in a manner that one person directly or indirectly controls or has
the power to control another.
b. "Provider" means any individual or entity furnishing Medicaid services under a
provider agreement with the department.
2. A provider, an affiliate of a provider, or any combination of provider and affiliates, is
liable to the department for up to twenty-five percent of the amount the department
was induced to pay as a result of each act of fraud or abuse. This sanction is in
addition to the applicable rules established by the department.
3. A provider, an affiliate of a provider, or any combination of provider and affiliates, is
liable to the department for up to five thousand dollars on each act of fraud or abuse
which did not induce the department to make an erroneous payment. This sanction is
in addition to the applicable rules established by the department.
4. A provider, an affiliate of a provider, or any combination of provider and affiliates, that
is assessed a civil sanction by the department also shall reimburse the department
investigation fees, costs, and expenses for any investigation and action brought under
this section.
5. Unless otherwise provided in a judgment entered against a provider or against an
affiliate of the provider, overpayments and sanctions accrue interest at the legal rate
beginning thirty days after the department provides written notice to the provider or the
affiliate of the provider.
6. a. A provider or an affiliate of a provider who is assessed a sanction may request a
review of the sanction by filing within thirty days of the date of the department's
notice of sanction a written notice with the department which includes a statement
of each disputed item and the reason or basis for the dispute.
b. A provider or an affiliate of a provider may not request review under this section if
the sanction imposed is termination or suspension and the notice of sanction
states that the basis for the sanction is either:
(1) The provider's or affiliate's failure to meet standards of licensure,
certification, or registration where those standards are imposed by state or
federal law as a condition to participation in the Medicaid program; or
(2) The provider or affiliate has been similarly sanctioned by the Medicare
program or by another state's Medicaid program.
c. Within thirty days after requesting a review, a provider or affiliate shall provide to
the department all documents, written statements, exhibits, and other written
information that supports the request for review.
d. The department shall assign a provider's or affiliate's request for review to
someone other than an individual who was involved in imposing the sanction. A
provider or affiliate who has requested review may contact the department for an
informal conference regarding the review any time before the department has
issued its final decision.
e. The department shall make and issue its final decision within seventy-five days of
receipt of the notice of request for review. The department's final decision must
conform to the requirements of section 28-32-39. A provider or affiliate may
appeal the final decision of the department to the district court in the manner
provided in section 28-32-42, and the district court shall review the department's
final decision in the manner provided in section 28-32-46. The judgment of the
district court in an appeal from a request for review may be reviewed in the
supreme court on appeal by any party in the same manner as provided in section
28-32-49.
f. Upon receipt of notice that the provider or affiliate has appealed its final decision
to the district court, the department shall make a record of all documents, written
statements, exhibits, and other written information submitted by the provider,
affiliate, or the department in connection with the request for review and the
department's final decision on review, which constitutes the entire record. Within
thirty days after an appeal has been taken to district court as provided in this
section, the department shall prepare and file in the office of the clerk of the
district court in which the appeal is pending the original and a certified copy of the
entire record, and that record must be treated as the record on appeal for
purposes of section 28-32-44.
7. Determinations of medical necessity may not lead to imposition of remedies, duties,
prohibitions, and sanctions under this section.
8. The remedies, duties, prohibitions, and sanctions of this section are not exclusive and
are in addition to all other causes of action, remedies, penalties, and sanctions
otherwise provided by law or by provider agreement.
9. The state's share of all civil sanctions, investigation fees, costs, expenses, and interest
received by the department under this section must be deposited into the general fund.