The federal Health and Human Services–Office of Inspector General (OIG) has the authority to exclude individuals and entities from participation in Medicare, Medicaid and other federal health care programs. MHCP also excludes individuals and entities from participation in MHCP if they are on either the federal or state excluded provider list.

See complete requirements in the Enrollment with MHCP and the Excluded Provider Lists sections.

Use of Billing Agents

Minnesota Health Care Programs (MHCP) providers may contract with a billing agent or organization to conduct transactions on their behalf. If a provider chooses to use a billing agent or organization, the provider must affiliate the billing agent with their enrollment record. Instructions for adding a billing agent to an enrollment record can be found on the Billing Organization/Responsibilities page of the MHCP Provider Manual.

Payment to Provider or Billing Agent

MHCP must make all payments to the provider. However, MHCP may mail payment to a billing agent (such as an accounting firm or billing service) that furnishes statements and receives payments in the name of the provider if the agent's compensation for these services is any of the following:

· Related to the cost of processing the billing

· Not related on a percentage (or other basis) to the amount that is billed or collected

· Not dependent on collection of the payment

Payment Reversals for Terminated Providers

MHCP pulls monthly reports to identify claims paid with dates of service on and after the effective date of the pay-to provider’s or rendering provider’s termination. MHCP will reprocess and reverse payments retroactive to six years following federal Required Provider Agreement regulations and Minnesota’s Covered Services rule that prohibits payment of a service to non-enrolled providers. Providers will see reversed claims as adjustments on their remittance advices.

Sale or Transfer of a Provider Entity

A change of ownership occurs when a business entity adds or removes a person or business that has a direct or indirect controlling interest of at least 5% or more in the business entity. A direct owner is any person or entity owns 5% or more of the enrolled provider entity. An indirect owner is any person or entity that has an ownership interest in an entity that directly or indirectly owns the enrolled provider entity.

When a change of ownership occurs, the provider must notify MHCP at least 30 days before the effective date of the sale or transfer. MHCP requires new copies of all enrollment documents as well as a copy of the Provider Entity Sale or Transfer Addendum (DHS-5550) (PDF). These can be submitted either by fax or through the Minnesota Provider Screening and Enrollment (MPSE) portal. When submitting through the MPSE portal, you must submit Enrollment Record Requests for each enrolled site, as well as a Global Request to update your owners and authorized people.

A new owner of an entity enrolled in MHCP must complete and comply with all provider screening and enrollment requirements and conditions. MHCP must approve the new entity owner’s enrollment before we can pay claims for any services they provide.

MCHP may suspend a provider’s ability to bill if the change in ownership is not complete prior to the date of sale or transfer date. DHS retains the right to pursue monetary recovery, or civil or criminal action against the seller or transferor.

If a new owner agrees to keep the NPI established for an entity (provider), as of the effective date of the sale or transfer of the provider, the following apply:

· The previous owner authorizes, and the new owner accepts all claims payments; claims adjustments will accrue to the new owner, without regard to the date of service, date of submission to MHCP, or adjudication date.

· MHCP will not recognize or enforce any agreement between the previous owner and the new owner. This does not limit the right of the previous owner and new owner to pursue other legal remedies.

· The previous owner’s access to MN–ITS, all future RAs and 835 transactions will transfer to the new owner; MHCP will not give information to the previous owner about adjustments; the previous owner must obtain any such information from the new owner.

· Any provider agreements, including addendums, executed by the previous owner on behalf of the provider will terminate.

Business entities that are reporting a change of ownership may contact the Provider Resource Center with any questions regarding the change in ownership process.

Impact for home care and waivered services

Advance notification to MHCP Provider Eligibility and Compliance is critical for providers of home care and waivered services due to the impact of a provider number change on service agreements through which they bill. See additional requirements in Home Care Services and HCBS Waiver Programs and EW and AC Program.

DHS Review and Notice to Provider

MHCP Provider Eligibility and Compliance reviews the provider's application and notifies the provider of its determination by U.S. Mail within 30 days of receipt of the application. Provider Eligibility and Compliance will notify the provider and ask for additional information if it is unable to make a determination. If Provider Eligibility and Compliance denies an initial provider enrollment application, the provider may not appeal the decision. If Provider Eligibility and Compliance terminates a provider, the provider has a right to an administrative appeal at the Office of Administrative Hearings (OAH).

Duration of MHCP Participation

MHCP participation remains in effect until any of the following occur:

· The ending date specified in the agreement

· The provider fails to comply with the terms of participation

· The provider sells or transfers ownership, assets, or control of an entity that has been enrolled to provide MHCP services

· Thirty days following the date of DHS' request to the provider to sign a new provider agreement, if the provider has not signed the new agreement

· The provider requests to end the agreement

Violating Provider Agreement

A provider who fails to comply with the terms of participation in the provider agreement or with requirements of the rules governing MHCP is subject to monetary recovery, Minnesota Rules, 9505 program sanctions, or civil or criminal action. Unless otherwise provided by law, no provider of health care services will be declared ineligible without prior notice and an opportunity for a hearing under Minnesota Statutes, 14.

Limits on Recipient Services

Minnesota Rules, 9505.0195, subp. 10, states in part:

"A provider shall not place restrictions or criteria on the services it will make available, the type of health conditions it will accept, or the persons it will accept for care or treatment, unless the provider applies those restrictions or criteria to all individuals seeking the provider's services. A provider shall render to recipients services of the same scope and quality as would be provided to the general public. Furthermore, a provider who has such restrictions or criteria shall disclose the restrictions or criteria to DHS so DHS can determine whether the provider complies with the requirements of this subpart."

For example, providers cannot deny treatment for a certain diagnosis (for example, pregnancy) to MHCP members unless treatment for that diagnosis is also not available for other clients. Requirements regarding the need for a referral, or which days are available for treatment, etc., are legitimate requirements for MHCP members only if they are also applied to other clients.

Nondiscrimination Notice

All MHCP enrolled providers must post a notice of nondiscrimination practices that is clearly visible in all the following locations:

· Physical locations where you interact with the public

· The home page of your company’s website (in an easily accessible location)

· In any significant publications and communications that target MHCP members or the public

The nondiscrimination notice must include all the following information:

· Your organization does not discriminate on the basis of race, color, national origin, sex, age, or disability.

· You provide appropriate accommodations for people with disabilities in a timely manner and free of charge when they are needed to perform services. Appropriate accommodations include assistive devices and services, interpreters and information in alternate formats.

· You provide timely language assistance services for people with limited English proficiency (LEP) free of charge when they are needed to perform services. Language assistance services include translated documents and oral language interpretation.

· You provide information on how someone can obtain accommodations or language assistance services from you.

· You include the name and contact information of an employee of your organization someone can contact to file a complaint about any of the items covered in the nondiscrimination notice.

· You give Information about filing a complaint with the Office for Civil Rights (OCR).

· There are taglines in at least the top 15 languages spoken by people with LEP in the state in which you operate, indicating that language assistance services are free of charge.

For small publications or communications, such as postcards or tri-fold brochures, the nondiscrimination statement may contain no less than the following information:

· Statement that your organization does not discriminate on the basis of race, color, national origin, sex, age, or disability

· Taglines in at least the top two languages spoken by people with LEP in the state in which you operate indicating that language assistance services are free of charge

Federal Anti-Fraud Statutes

Federal anti-fraud and abuse provisions prohibit certain types of business transactions or arrangements. A pertinent provision of these statutes is: Whoever knowingly and willfully offers; pays or solicits; or receives any compensation (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or non-cash compensation:

· To refer, or in return for referring, an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under the MHCP program or

· To refer, or in return for purchasing, leasing, ordering, or arranging for or recommending, purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part, shall be guilty of a felony and upon conviction thereof, shall be fined not more than $25,000 or imprisoned for not more than five years or both.

The following practices are prohibited:

Offering or compensating to any individual eligible for benefits under this program, that such person knows or should know is likely to influence such individual to order or receive from a particular provider, practitioner or supplier any item or service for which payment may be made in whole or in part by this program. Examples of benefits include, but are not limited to, coupons providing discounts, cash, merchandise or other goods or services of value in exchange for services or obtaining goods from a particular provider.

Factors

Factor: An individual or organization that advances money to a provider for their accounts receivable for an added fee or a deduction of the accounts receivable worth. Payment for any covered service furnished to a member by a provider may not be made to or through a factor, either directly or indirectly. A factor doesn’t include a business representative.

Advance Directives

Background

Inpatient hospitals, nursing facilities, providers of home health and personal care services, hospice programs and managed care plans are required by federal and state law to inform all adult patients about their rights to accept or refuse medical or surgical treatment, and the right to execute an advance directive. Out-of-state providers must comply with all terms of this section and follow laws of the state in which the provider is located.

Definitions

Advance Directive: A written instruction such as a living will or durable power of attorney for health care, recognized under state law and relating to the provision of care when the patient is incapacitated. The intent of an advance directive is to enhance a patient's control over medical treatment decisions.

Patient: Any adult resident, patient, member, or client receiving medical care from or through the provider.

Requirements

Inpatient hospitals, nursing facilities, providers of home health and personal care services, hospice programs and managed care plans must maintain written policies and procedures as well as the following:

· Give updated, written information to all patients about their rights under state law to make decisions concerning their medical care, including the right to accept or refuse medical or surgical treatment and to execute an advance directive. Providers may contract with other entities to furnish this information but are still legally responsible for ensuring this requirement.

· Give written information to patients regarding the provider's policies and procedures concerning implementation of these rights, including a clear and precise statement of limitation if the provider cannot implement an advance directive based on conscience. At a minimum, the provider's statement of limitation should include the following:

· Clarify any differences between institution-wide conscientious objections and those that may be raised by individual physicians.

· Identify the state legal authority permitting such objection.

· Describe the range of medical conditions or procedures affected by the conscientious objection.

· Within limited circumstances, only if allowed under state law, a facility or physician may conscientiously object to an advance directive. If state law is silent regarding conscientious objection, the facility or physician may not conscientiously object to an advance directive that is permissible in that state.

· Document in the patient's medical record whether the patient has executed an advance directive.

· Refrain from conditioning the provision of care, or otherwise discriminating against the patient, based on whether the patient has executed an advance directive.

· Comply with state law governing advance directives.

· Provide for educational campaigns, individually or with other providers and organizations, to educate staff and the community on issues concerning advance directives. This requirement may be met by making copies of the required documents available in reception areas.

Providers are encouraged to work with associations and advocacy groups to further educate the community on these issues. Providers must be able to document their community education efforts.

When Providers Must Inform Patients

According to federal law, the following providers must give written information on state laws regarding the patient's right to make decisions and the provider's policies concerning implementation of those rights at the following times:

· Inpatient hospitals, at the time of the person’s admission as an inpatient

· Nursing facilities, at the time of the person’s admission as a resident

· Home health or personal care services providers, in advance of the person coming under the care of the provider (this means on or before the initial visit)

· Hospice programs, at the time of the person’s initial receipt of hospice care

· HMOs, at the time the person enrolls with the organization

Patient Incapacity

If a patient is incapacitated at one of the above times, and if the provider issues materials about policies and procedures to families, surrogates, or other concerned persons, the provider must include in those materials the information about advance directives. Document in the medical record that the patient was unable to receive the information or was unable to articulate whether he or she has executed an advance directive. Once the patient is no longer incapacitated, give the information on advance directives to the individual. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Executed Advance Directives

Document in the patient's medical record whether the patient has executed an advance directive. If the patient has an advance directive and has given the provider a copy, the provider must comply with the terms of the advance directive, to the extent allowed under state law.

Objection Based on Conscience

Federal law does not affect the rights a provider may have under state law to object, based on conscience, to the treatment or withdrawal of an advance directive.

Informed Consent

Federal law does not affect a provider's obligation to obtain informed consent to treatment.

Forms Available

Although providers are not required by law to assist patients in formulating advance directives, providers may wish to have copies of the Minnesota Health Care Declaration (living will) form or the Durable Power of Attorney for Health Care form available for patients who request one. The Minnesota Health Care Directive suggested form is found in Minnesota Statutes, 145C.

Mandatory Reporting

Adult maltreatment

As a professional or professional’s delegate engaged in social services and the care of vulnerable adults, MHCP enrolled providers are mandated reporters under Minnesota Statutes, 626.557. Under Minnesota law, all enrolled providers are required to report all suspected maltreatment including abuse, neglect or financial exploitation of a vulnerable adult to the common entry point following the requirements in Minnesota Statutes, 626.557, subd. 4.

Child maltreatment

MHCP providers are also mandated by law to report suspected maltreatment, abuse or child neglect. Refer to child protection programs and services for more information. Report concerns about abuse or neglect to your county or tribal agency.

Program Integrity Oversight Division (PIOD)

Background

Minnesota Rules, 9505.2160 to 9505.2245 established a program of surveillance, integrity, review and control. They authorize a post-payment review process to ensure compliance with MHCP requirements. The review process monitors the use of health services by MHCP members and the delivery of health services by vendors. Within DHS, the PIOD is responsible for identifying and investigating suspected fraud, theft, and abuse. PIOD is authorized to seek monetary recovery, to impose administrative sanctions, and to seek civil or criminal action through the office of Attorney General (AG). Referrals are made both to the Medicaid Fraud Control Unit (MFCU), and to the civil section of the AG's office. Information about the monitoring of member use of health services is found in Health Care Programs and Services.

Definitions

Abuse: In the case of a vendor, a pattern of practice inconsistent with sound fiscal, business, or health service practices, and that results in unnecessary costs to MHCP or in reimbursement for services not medically necessary, or that fail to meet professionally recognized standards for health services. The following practices are deemed to be abuse by a provider:

Submitting repeated claims as follows:

· With missing or incorrect information

· Using procedure codes that overstate the level or amount of health service provided

· For health services that are not reimbursable by MHCP

· For the same health service provided to the same member

· For health services that do not comply with the requirements to be a covered service under Minnesota Rules, 9505.0210 and, if applicable, Minnesota Rules, 9505.0215

· For services not medically necessary

· Failing to develop and maintain health service records as required under Minnesota Rules, 9505.2175

· Failing to use generally accepted accounting principles or other accounting methods which relate entries on the member’s health service record to corresponding entries on the billing invoice, unless another accounting method or principle is required by federal or state law or rule

· Failing to disclose or make available to DHS the member’s health service records or the vendor's financial records as defined under Minnesota Rules, 9505.2180

· Repeatedly failing to report duplicate payments from third-party payers for covered services provided to MHCP members and billed to DHS

· Failing to obtain information and assignment of benefits as specified in Minnesota Rules, 9505.0070, subp. 3, or

· Failing to bill Medicare as required by Minnesota Rules, 9505.0440;

· Failing to keep financial records as defined under Minnesota Rules, 9505.2180

· Repeatedly submitting or causing repeated submission of false information for the purpose of obtaining (prior) authorization, inpatient hospital admission certification, or a second medical opinion

· Knowingly and willfully submitting a false or fraudulent application for provider status

· Soliciting, charging, or receiving payments from members or non-Medical Assistance sources, in violation of Code of Federal Regulations, title 42, section 447.15, or Minnesota Rules, 9505.0225, for services for which the vendor has received reimbursement from, or should have billed to, MHCP

· Payment of program funds by a vendor to another vendor whom the vendor knew or had reason to know was suspended or terminated from MHCP participation

· Repeatedly billing MHCP for health services after entering into an agreement with a third-party payer to accept an amount in full satisfaction of the payer's liability

· Repeatedly failing to comply with the requirements of the provider agreement that relate to the programs covered by Minnesota Rules, 9505.2160 to 9505.2245

Electronically Stored Data: Data stored in a typewriter, word processor, computer, existing or pre-existing computer system or computer network, magnetic tape, or computer disk.

Fraud: Acts which constitute a crime against any program, or attempts or conspiracies to commit those crimes including the following:

· Theft, perjury, forgery and aggravated forgery, MA fraud, or financial transaction card fraud

· Making a false statement, claim, or representation to a program where the person knows or should reasonably know the statement, claim, or representation is false

· A felony listed in United States Code, title 42, section 1320a-7b(b)(3)(D) subject to any safe harbors established in Code of Federal Regulations, title 42, part 1001, section 952

Health Plan: A managed care organization that contracts with DHS to provide health services to members under a prepaid contract.

Health Services: Goods and services eligible for MHCP payment under Minnesota Statutes, 256B.02, subd. 8, and Minnesota Statutes, 256B.0625.

Health Service Record: Electronically stored data, and written or diagrammed documentation of the nature, extent, and evidence of the medical necessity of a health service provided to a member by a vendor and billed to MHCP.

Investigative Costs: Investigative costs are subject to the provisions of Minnesota Statutes, 256B.064, subd. 1d, and means the sum of the following expenses incurred by a DHS investigator on a particular case:

· Hourly wage multiplied by the number of hours spent on the case

· Employee benefits

· Travel

· Lodging

· Meals

· Photocopying costs, paper, computer data storage or diskettes, and computer records and printouts

Medically Necessary or Medical Necessity: A health service that is consistent with the member’s diagnosis and condition and:

· Is recognized as the prevailing standard or current practice by the provider's peer group

· Is rendered in response to a life-threatening condition or pain; to treat an injury, illness, or infection; to treat a condition that could result in physical or mental disability; to care for a mother and child through the maternity period; or to achieve a level of physical or mental function or

· Is a preventive health service

Ownership or Control Interest: Has the meaning given in Code of Federal Regulations, title 42, part 455, sections 101 and 102.

Pattern: An identifiable series of more than one event or activity.

MHCP (Minnesota Health Care Programs): The Medical Assistance (MA) Program, MinnesotaCare, Behavioral Health Fund (BHF) Program, Prepaid Medical Assistance Program (PMAP), home and community-based services under a waiver from the Centers for Medicare & Medicaid Services (CMS), or any other DHS-administered health service program.

MPSE (Minnesota Provider Screening and Enrollment) Portal: A secure online web-based tool that lets providers enroll and manage their enrollment records with MHCP. The online MPSE User Manual is the primary information source for the MPSE portal enrollment process.

Provider: An individual, organization, or entity that has entered into an agreement with DHS for the provision of health services, including a personal care assistant.

Restriction: In the case of a vendor, excluding or limiting the scope of the health services for which a vendor may receive a payment through a program for a reasonable time.

Suspending Participation or Suspension: Making a vendor ineligible for reimbursement through MHCP funds for a stated period.

Suspending Payments: Stopping any or all program payments for health services billed by a provider pending resolution of the matter in dispute between the provider and DHS.

Terminating Participation or Termination: Making a vendor ineligible for reimbursement through MHCP funds.

Theft: The act defined in Minnesota Statutes, 609.52, subd. 2.

Third Party Payer: The term defined in Minnesota Rules, 9505.0015, subp. 46, and, additionally, Medicare.

Vendor: The meaning given to "vendor of medical care" in Minnesota Statutes, 256B.02, subd. 7. The term vendor includes a provider and a personal care assistant.

Withholding Payments: Reducing or adjusting the amounts paid to a provider to offset overpayments previously made to the provider.

Health Service Records

Documentation: Health service records must be developed and maintained as a condition of payment by MHCP. Document each occurrence of a health service in the recipient's health record. MHCP funds paid for health care not documented in the health service record are subject to monetary recovery.

Health Service Records: In addition to those listed here, there may be other record obligations located throughout this manual specific to vendors of a particular service. Records must contain the following information when applicable:

· The record must be legible at a minimum to the individual providing care

· The member’s name must be on each page of the recipient's record

· Each entry in the health service record must contain:

· The date on which the entry is made

· The date or dates on which the health service is provided

· The length of time spent with the recipient, if the amount paid for the service depends on time spent

· The signature and title of the person from whom the recipient received the service

· Reportage of the member’s progress or response to treatment, and changes in the treatment or diagnosis

· When applicable, the countersignature of the vendor or the supervisor as required under Minnesota Rules, 9505.0170 to 9505.0475

· Documentation of supervision by the supervisor

· The record must state:

· The member’s case history and health condition as determined by the vendor's examination or assessment,

· The results of all diagnostic tests and examinations, and

· The diagnosis resulting from the examination.

· The record must contain reports of consultations that are ordered for the member.

· The record must contain the member’s plan of care, individual treatment plan, or individual program plan.

· The record of a laboratory or X-ray service must document the provider's order for service.

Health Service Records of Specific Providers

The following vendors must comply with these additional requirements in their health service records:

Pharmacy service record must comply with Minnesota Rules relating to pharmacy licensing and operations and electronic data processing of pharmacy records. The pharmacy service record must be a hard copy made at the time of the request for service and must be kept for five years.

Medical transportation record must document:

· The origin, destination, and distance traveled in providing the service to the member

· The type of transportation

· If applicable, a physician's certification for nonemergency, ancillary, or special transportation services as defined in Minnesota Rules, 9505.0315, subp. 1

Medical supplies and equipment record must:

· Document that the medical supply or equipment is eligible for payment.

· Contain the physician’s order or prescription, including the name and amount of the medical supply or equipment provided for the member. The physician’s order or prescription maintained by the medical supplier may be a photocopy or fax image, electronically maintained, or original “pen-and-ink” document. Follow the requirements for electronically maintained records as stated in Minnesota Rules, 9505.2190, subpart 1 and Minnesota Rules, 9505.2197.

Rehabilitative and therapeutic service records must comply with requirements listed in Rehabilitation Services.

Personal care provider records must comply with additional documentation requirements in the Personal Care Assistance (PCA) Services section of this manual.

Record Keeping Requirements

Providers must follow MHCP record keeping requirements as required by law. Financial records, including written and electronically stored data, of a vendor who receives payment for a member’s services under MHCP must contain:

· Payroll ledgers, canceled checks, bank deposit slips and any other accounting records prepared by or for the vendor

· Contracts for services or supplies relating to the vendor's costs and billings to MHCP for the member’s health services

· Evidence of the vendor charges to MHCP members and to people who are not MHCP members, consistent with the requirements of Minnesota Government Data Practices Act

· Evidence of claims for reimbursement, payments, settlements, or denials resulting from claims submitted to third party payers or programs

· The vendor's appointment books for patient appointments and the provider's schedules for patient supervision, if applicable

· Billing transmittal forms

· Records showing all persons, corporations, partnerships, and entities with an ownership or controlling interest in the vendor

· Employee records for those persons currently employed by the vendor (or who have been employed by the vendor at any time within the previous five years) which, under the Minnesota Government Data Practices Act, would be considered public data for a public employee, such as employee name, salary, qualifications, position description, job title, and dates of employment. In addition, employee records must include the current home address of the employee or the last known address of any former employee

· Nursing or board and care homes must, in addition to the foregoing, maintain purchase invoices, records of deposits, expenditures for patient personal needs and allowance accounts

Access to Records
Vendors must give DHS access to members’ health services and financial records related to billing during normal business hours of 8 a.m. and 5 p.m. on the day of request. DHS will notify the vendor at least 24 hours in advance of a request for records access unless the vendor waives the notice requirement. Vendors must provide records access at the vendor’s place of business unless the vendor and DHS agree on an alternative location. Access to a member's health service record or vendor's records is for the purposes of identifying and preventing fraud, theft, abuse or error.

DHS, at its own expense, may copy or otherwise duplicate any health service or financial record related to a health service for which a claim or payment is made under an MHCP program. The copying shall be done on the vendor’s premises unless removal is specifically permitted by the vendor. If a vendor does not allow DHS to use DHS equipment to copy or duplicate the records on the premises, the vendor must furnish copies at the vendor’s expense within two weeks of a request for copies by DHS.

Record Retention
Vendors must retain all health and financial records related to a health service received or paid under MHCP for at least five years after the initial date of billing. Microfilm records satisfy the recordkeeping requirements in the fourth and fifth years after the date of billing.

Vendors may maintain records in an electronic health records system for all or part of the five-year record keeping period. However, the vendor must ensure the electronic storage meets all record-keeping requirements, including allowing DHS access to copy the records when requested.

A vendor who withdraws or is terminated from an MHCP program must retain the health services and financial records of MHCP members. These vendors must also make these retained records available to DHS upon request.

If the owner(s) of a long-term care facility or vendor changes, the person transferring ownership is responsible for maintaining and making available to DHS the health services and financial records of MHCP members. This applies to records related to services provided before the date of ownership transfer unless otherwise provided by law or written agreement between the old and new owner(s).

In the event of a contested case under Minnesota Statutes, chapter 14, the vendor must retain health service and financial records as required by Minnesota Rules, 9505.2190 subp. 1 or for the duration of the contested case proceedings, whichever period is longer.

Investigative Process

· PIOD has the authority to conduct routine audits of vendors to monitor compliance with program requirements.

· PIOD is authorized to use information from sources including:

· Government agencies; Third-party payers including Medicare

· Professional review organizations

· Members and their responsible relatives

· Vendors and persons employed by or under contract to vendors

· Professional associations of vendors and their peers; Member advocacy organizations and members

· Members of the public

· A PIOD investigation may include, but is not limited to:

· Examination of health service and financial records

· Examination of equipment, materials, prescribed drugs, or other items used in or for a recipient's health service under MHCP

· Examination of prescriptions written for MHCP members

· Interviews of contacts

· Verification of the professional credentials of a vendor, the vendor's employees and entities under contract with the vendor

· Consultation with DHS peer review mechanisms

· Determination of whether the health care provided was medically necessary

Monetary Recovery and Sanctioning

· Following completion of the investigation, DHS will determine whether:

· The vendor is complying with the requirements of a program.

· Insufficient evidence exists that fraud, theft, or abuse has occurred, or

· The evidence of fraud, theft, or abuse supports administrative, civil, or criminal action.

· After completing the determination, DHS will take one or more of the actions specified in items listed below:

· Close the investigation when no further action is warranted

· Impose administrative sanctions

· Seek monetary recovery

· Refer the investigation to the appropriate state regulatory agency

· Refer the investigation to the attorney general or, if appropriate, to a county attorney for possible civil or criminal legal action

· Issue a warning that states the practices are potentially in violation of program laws or regulations

· Seek monetary recovery from a vendor if payment for a member’s health service under MHCP was the result of fraud, theft, abuse or error on the part of the provider, DHS or local agency. The commissioner is authorized to calculate the amount of monetary recovery based on estimation from systematic random samples of claims submitted and paid. The commissioner will recover money by the following means:

· Permitting voluntary repayment of money, either in lump sum payment or installment payments

· Deducting or withholding from MHCP payments

· Withholding payments to a provider under Code of Federal Regulations, title 42, section 447.31

· Using any legal collection process

If DHS permits use of installment payments, DHS shall assess interest on the funds, unless the overpayment occurred because of department error. The Department of Revenue establishes the rate under Minnesota Statutes, 270C.40.

· If a vendor willfully submits a claim for reimbursement for medical care or services the vendor knows or reasonably should have known is a false representation, and which results in payments for which the vendor is ineligible, DHS may seek recovery of investigative costs.

· Administrative sanctions may be imposed for any of the following:

· Fraud, theft, or abuse in connection with health care services billed to MHCP

· Refusal to grant DHS access to records

· Additional actions or sanctions that may be imposed are:

· Referral to the appropriate peer review mechanism or licensing board

· Suspending or terminating the provider's or vendor's participation

· Suspending or terminating the participation of any person or corporation with whom the provider or vendor has any ownership or controlling interest

· Requiring attendance at education sessions provided by DHS

· Requiring authorization of services

· Restricting the vendor's participation in MHCP

· For a provider, the sanctions that may be imposed are those described in previous, as well as:

· Requiring a provider agreement of limited duration

· Requiring a provider agreement which stipulates specific conditions of participation

· Review of the provider's claims before payment

· DHS has the authority to simultaneously seek monetary recovery and to administer sanctions.

· DHS will notify vendors in writing of any intent to recover money or impose sanctions.

· A vendor may meet with DHS informally to discuss the matter in dispute.

· A vendor has the right to appeal DHS' proposed action. An appeal is considered timely if written notice of appeal is filed with the commissioner within 30 days of the date that the notice of proposed action was mailed. The appeal request must specify:

· Each disputed item

· The reason for the dispute

· An estimate of the dollar amount involved, if any, for each disputed item

· The computation or other disposition that the appealing party believes is correct

· The authority in statute or rule upon which the appealing party relies for each disputed item

· The name and address of the person or firm with whom contracts may be made regarding the appeal

· Other information required by the commissioner

· The appeal shall be a contested case proceeding under the provisions of the Minnesota Administrative Procedure Act

· Under certain conditions, DHS has the authority to withhold payments to vendor prior to notice or to a hearing

· A vendor who has been suspended or terminated from MHCP may not submit claims personally, nor may any clinic, group, corporation, or association submit claims on behalf of a vendor who has been suspended or terminated from MHCP. Claims for health care provided prior to the suspension or termination may be submitted, but will be subject to review.

· The vendor who is restricted from participation may not submit a claim for payment under MHCP for services or charges specified in the notice of action, either through a claim as an individual or through a claim submitted by a clinic, group, corporation, or professional association, except in the case of claims for payment for health services otherwise eligible for payment and provided before the restriction. No payments may be made to a vendor either directly or indirectly, for restricted services or charges specified in the notice of action.

· A vendor who is convicted of a crime related to the provision, management, or administration of MHCP related health services will be suspended from participation effective on the date of conviction. The commissioner will notify the vendor of the date and duration of the suspension.

Fraud or Abuse of Medicare Program

DHS will suspend or terminate any vendor who has been suspended or is currently under suspension or termination from participation in the Medicare program because of fraud or abuse.

Reporting Suspected Fraud or Abuse

If you suspect either a treating or rendering provider, or a provider group or agency, of fraud, abuse or improper billing, contact PIOD. Also see How to submit tips.

Kickbacks and Other Criminal Activities

A vendor who commits any of the following acts may be convicted of a felony and fined up to $25,000 or imprisoned for up to five years, or both:

· Makes a statement known to be false in an application for payment or for use in determining rights to such payment

· Fails to disclose a fact affecting the vendor's initial or continuing right to receive payments with the intent to wrongfully obtain such payments

· Receives payments for the benefit of another and knowingly uses them for a purpose other than on behalf of the beneficiary

· Receives, solicits, offers, or pays in any manner and in any form in return for:

· Referring, or inducing another to refer, a recipient for the furnishing of benefits for which payment may be made under this program or

· Obtaining, or inducing another to obtain, in any manner, goods or services for which payment may be made under this program

This does not apply to:

· A properly disclosed reduction in price that is reflected in cost claimed by the provider

· Salaries paid by an employer to an employee

Crimes Related to MHCP

Convicted: A judgment of conviction has been entered by a federal, state, or local court, regardless of whether an appeal from the judgment is pending and includes a plea of guilty or nolo contendere (a plea accepted without admitting guilt).

· A vendor convicted of an MHCP-related crime is automatically suspended from participation in MHCP. The effective date of the suspension is the date of the conviction. The commissioner will notify the vendor of the date and duration of the suspension.

· Suspension and termination sanctions are applicable to vendors who share ownership or control interest with a vendor convicted of a crime related to MHCP. The determination of ownership or control interest will be made using the definitions in Code of Federal Regulations, title 42, sections 455.101 and 455.102. A provider suspended under this provision may seek reinstatement as a provider when the convicted provider ceases ownership or control interest in the other provider.

· A vendor will be notified in writing of DHS' intent to suspend the vendor from MHCP participation, the reasons for the suspension, and the effective date and duration of the suspension.

Additional Resources

HITECH Act
Health Information Privacy – HIPAA

Legal References

Minnesota Statutes, 14 (Administrative Procedure)
Minnesota Statutes, 145C (Health Care Directives)
Minnesota Statutes, 62D.04, subd. 5 (Issuance of Certificate of Authority)
Minnesota Statutes, 256B.02 (Definitions)
Minnesota Statutes, 246B.03 (Payments to Vendors)
Minnesota Statutes, 256B.04 (Duties of State Agency)
Minnesota Statutes, 256B.27 (MA; Cost Reports)
Minnesota Statutes, 256B.48 (Conditions for Participation)
Minnesota Statutes, 256B.0625 (Covered Services)
Minnesota Statutes, 256B.064 (Sanctions; Monetary Recovery)
Minnesota Statutes, 256B.0644 (Reimbursement Under Other State Health Care Programs)
Minnesota Statutes, 256B.434 (Payment Rates and Procedures; Contracts and Agreements)
Minnesota Statutes, 270C.40 (Interest Payable to Commissioner)
Minnesota Statutes, 363A.36 (Certificates of Compliance for Public Contracts)
Minnesota Statutes, 609.52, subd. 2 (Acts constituting theft)
Minnesota Rules, 9505 (Health Care Programs)
Minnesota Rules, 9505.0015 (Definitions)
Minnesota Rules, 9505.0070 (Third-Party Liability)
Minnesota Rules, 9505.0140 (Payment for Access to Medically Necessary Services)
Minnesota Rules, 9505.0170 to 9505.0475 (Medical Assistance Payments)
Minnesota Rules, 9505.0195 (Provider Participation)
Minnesota Rules, 9505.0210 (Covered Services; General Requirements)
Minnesota Rules, 9505.0215 (Covered Services; Out-of-State Providers)
Minnesota Rules, 9505.0225 (Request to Recipient to Pay)
Minnesota Rules, 9505.0315 (Medical Transportation)
Minnesota Rules, 9505.0440 (Medicare Billing Required)
Minnesota Rules, 9505.2160 to 9505.2245 (Surveillance and Integrity Review Program)
Minnesota Rules, 9505.2175 (Health Care Records)
Minnesota Rules, 9505.2180 (Financial Records)
Minnesota Rules, 9505.2185 (Access to Records)
Minnesota Rules, 9505.2190 (Retention of Records)
Minnesota Rules, 9505.2195 (Copying Records)
Minnesota Rules, 9505.2197 (Vendor’s Responsibility for Electronic Records)
Minnesota Rules, 9505.2200 (Identifying Fraud, Theft, Abuse, or Error)
Minnesota Rules, 9505.5200 to 9505.5240 (Department Health Care Program Participation) Requirements for Vendors and Health Maintenance Organizations
Section 504 of the Rehabilitation Act of 1973
Social Security Act, title 11, section 1128(b) (formerly Title 19, section 1909)
Social Security Act, title 18, section 1877(b)
Code of Federal Regulations, title 42, section 431.53 (Assurance of transportation)
Code of Federal Regulations, title 42, section 431.107 (Required provider agreement)
Code of Federal Regulations, title 42, section 447.10 (Prohibition against reassignment of provider claims)
Code of Federal Regulations, title 42, section 455 (Program Integrity: Medicaid)
Stipulated Settlement Agreement Day v. Noot

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