SECTION 357.588. Administrative Sanctions and Actions

(a) The following sanctions may be imposed against providers for any reason specified in §79.2105 of this title (relating to Grounds for Fraud Referral and Administrative Sanction):

(1) exclusion from participation in the Titles XIX and XX programs for a specified period of time;

(2) suspension of payments (payment hold) to a provider;

(3) recoupment of overpayments;

(4) recoupment of overpayments projected from a sampling process; and

(5) restricted reimbursement from the Titles XIX and XX programs for a specified period of time.

(b) A sanction may be imposed even if none of the administrative actions listed in subsection (c) of this section has been imposed.

(c) Administrative actions may include but are not limited to the following:

(1) referral to peer review outside the department;

(2) transfer to a closed-end provider agreement for a specified period of time;

(3) attendance at provider education sessions;

(4) prior authorization of selected services;

(5) review of all services before payment;

(6) review of all services after payment;

(7) referral to the appropriate state licensing board;

(8) referral to the department of health and human services, including referral for action under the Civil Monetary Penalties Law (the Social Security Act, §1128);

(9) attendance in informal or formal provider corrective action meetings;

(10) submittal of additional justification that is not normally required to accompany submitted claims;

(11) oral, written, or personal educational contact with the provider;

(12) posting of a surety bond; and

(13) referral for recovery through judicial means of all overpayments.

(d) The department must exclude providers from participation in the Titles XIX and XX programs for at least the period of time directed by the Department of Health and Human Services. Additionally, the department excludes from participation in the Titles XIX and XX programs, for a minimum period of one year beyond the exclusion, commensurate with the severity of the offense, any person excluded for fraud or abuse or under the provisions allows in the Act.

(e) Providers are afforded all administrative and judicial due process remedies applicable to administrative actions and sanctions as specified in Subchapter Q of this chapter (relating to Contract Appeals).

(f) The department must exclude from participation in Titles XIX and XX programs for a minimum of five years any person who has been convicted under federal or state law of a criminal offense related to:

(1) delivery of an item or service under Title XVIII (medicare) or under any state health care program; or

(2) neglect or abuse of patients in connection with the delivery of a health care item or service.

(g) The department may exclude a partnership, corporation, association, or other legal entity in which an individual, who has an ownership or controlling interest in that entity as defined in the Social Security Act, §1124(a) (3) or is an officer, director, agent, or managing employee in that entity as defined in the Social Security Act, §1126(b), has been:

(1) convicted of any offense described in subsection (f) of this section, or §79.2105(16), (29), (30) or (32) of this title (relating to Grounds for Fraud Referral and Administrative Sanction);

(2) assessed with a civil monetary penalty under the Social Security Act, §1128A; or

(3) excluded from participation under a program under Title XVIII or under a state health care program.

Source Note: The provisions of this §357.588 adopted to be effective July 1, 1986, 11 TexReg 2825; amended to be effective December 15, 1988, 13 TexReg 5828; transferred effective September 1, 2004, as published in the Texas Register September 17, 2004, 29 TexReg 9013