2004 Minnesota Statutes

     256B.064 Sanctions; monetary recovery. 

    Subdivision 1.    Terminating payments to ineligible 
 vendors.  The commissioner may terminate payments under this 
 chapter to any person or facility that, under applicable federal 
 law or regulation, has been determined to be ineligible for 
 payments under Title XIX of the Social Security Act. 

    Subd. 1a.    Grounds for sanctions against vendors.  The 
 commissioner may impose sanctions against a vendor of medical 
 care for any of the following:  (1) fraud, theft, or abuse in 
 connection with the provision of medical care to recipients of 
 public assistance; (2) a pattern of presentment of false or 
 duplicate claims or claims for services not medically necessary; 
 (3) a pattern of making false statements of material facts for 
 the purpose of obtaining greater compensation than that to which 
 the vendor is legally entitled; (4) suspension or termination as 
 a Medicare vendor; (5) refusal to grant the state agency access 
 during regular business hours to examine all records necessary 
 to disclose the extent of services provided to program 
 recipients and appropriateness of claims for payment; (6) 
 failure to repay an overpayment finally established under this 
 section; and (7) any reason for which a vendor could be excluded 
 from participation in the Medicare program under section 1128, 
 1128A, or 1866(b)(2) of the Social Security Act.  The 
 determination of services not medically necessary may be made by 
 the commissioner in consultation with a peer advisory task force 
 appointed by the commissioner on the recommendation of 
 appropriate professional organizations.  The task force expires 
 as provided in section 15.059, subdivision 5. 

    Subd. 1b.    Sanctions available.  The commissioner may 
 impose the following sanctions for the conduct described in 
 subdivision 1a:  suspension or withholding of payments to a 
 vendor and suspending or terminating participation in the 
 program.  Regardless of imposition of sanctions, the 
 commissioner may make a referral to the appropriate state 
 licensing board. 

    Subd. 1c.    Grounds for and methods of monetary recovery. 
  (a) The commissioner may obtain monetary recovery from a 
 vendor who has been improperly paid either as a result of 
 conduct described in subdivision 1a or as a result of a vendor 
 or department error, regardless of whether the error was 
 intentional.  Patterns need not be proven as a precondition to 
 monetary recovery of erroneous or false claims, duplicate 
 claims, claims for services not medically necessary, or claims 
 based on false statements.  

    (b) The commissioner may obtain monetary recovery using 
 methods including but not limited to the following:  assessing 
 and recovering money improperly paid and debiting from future 
 payments any money improperly paid.  The commissioner shall 
 charge interest on money to be recovered if the recovery is to 
 be made by installment payments or debits, except when the 
 monetary recovery is of an overpayment that resulted from a 
 department error.  The interest charged shall be the rate 
 established by the commissioner of revenue under section 270.75. 

    Subd. 1d.    Investigative costs.  The commissioner may 
 seek recovery of investigative costs from any vendor of medical 
 care or services who willfully submits a claim for reimbursement 
 for services that the vendor knows, or reasonably should have 
 known, is a false representation and that results in the payment 
 of public funds for which the vendor is ineligible.  Billing 
 errors that result in unintentional overcharges shall not be 
 grounds for investigative cost recoupment. 

    Subd. 2.    Imposition of monetary recovery and sanctions. 
  (a) The commissioner shall determine any monetary amounts to 
 be recovered and sanctions to be imposed upon a vendor of 
 medical care under this section.  Except as provided in 
 paragraphs (b) and (d), neither a monetary recovery nor a 
 sanction will be imposed by the commissioner without prior 
 notice and an opportunity for a hearing, according to chapter 
 14, on the commissioner's proposed action, provided that the 
 commissioner may suspend or reduce payment to a vendor of 
 medical care, except a nursing home or convalescent care 
 facility, after notice and prior to the hearing if in the 
 commissioner's opinion that action is necessary to protect the 
 public welfare and the interests of the program. 

    (b) Except for a nursing home or convalescent care 
 facility, the commissioner may withhold or reduce payments to a 
 vendor of medical care without providing advance notice of such 
 withholding or reduction if either of the following occurs: 

    (1) the vendor is convicted of a crime involving the 
 conduct described in subdivision 1a; or 

    (2) the commissioner receives reliable evidence of fraud or 
 willful misrepresentation by the vendor. 

    (c) The commissioner must send notice of the withholding or 
 reduction of payments under paragraph (b) within five days of 
 taking such action.  The notice must: 

    (1) state that payments are being withheld according to 
 paragraph (b); 

    (2) except in the case of a conviction for conduct 
 described in subdivision 1a, state that the withholding is for a 
 temporary period and cite the circumstances under which 
 withholding will be terminated; 

    (3) identify the types of claims to which the withholding 
 applies; and 

    (4) inform the vendor of the right to submit written 
 evidence for consideration by the commissioner. 

    The withholding or reduction of payments will not continue 
 after the commissioner determines there is insufficient evidence 
 of fraud or willful misrepresentation by the vendor, or after 
 legal proceedings relating to the alleged fraud or willful 
 misrepresentation are completed, unless the commissioner has 
 sent notice of intention to impose monetary recovery or 
 sanctions under paragraph (a). 

    (d) The commissioner may suspend or terminate a vendor's 
 participation in the program without providing advance notice 
 and an opportunity for a hearing when the suspension or 
 termination is required because of the vendor's exclusion from 
 participation in Medicare.  Within five days of taking such 
 action, the commissioner must send notice of the suspension or 
 termination.  The notice must: 

    (1) state that suspension or termination is the result of 
 the vendor's exclusion from Medicare; 

    (2) identify the effective date of the suspension or 
 termination; 

    (3) inform the vendor of the need to be reinstated to 
 Medicare before reapplying for participation in the program; and 

    (4) inform the vendor of the right to submit written 
 evidence for consideration by the commissioner. 

    (e) Upon receipt of a notice under paragraph (a) that a 
 monetary recovery or sanction is to be imposed, a vendor may 
 request a contested case, as defined in section 14.02, 
 subdivision 3, by filing with the commissioner a written request 
 of appeal.  The appeal request must be received by the 
 commissioner no later than 30 days after the date the 
 notification of monetary recovery or sanction was mailed to the 
 vendor.  The appeal request must specify: 

    (1) each disputed item, the reason for the dispute, and an 
 estimate of the dollar amount involved for each disputed item; 

    (2) the computation that the vendor believes is correct; 

    (3) the authority in statute or rule upon which the vendor 
 relies for each disputed item; 

    (4) the name and address of the person or entity with whom 
 contacts may be made regarding the appeal; and 

    (5) other information required by the commissioner. 

    HIST: 1973 c 717 s 6; 1976 c 188 s 1; 1980 c 349 s 5,6; 1982 c 
 424 s 130; 1983 c 312 art 5 s 17; 1987 c 370 art 1 s 4; 1987 c 
 403 art 2 s 81; 1988 c 629 s 52; 1991 c 292 art 5 s 29; 1992 c 
 513 art 7 s 51,52; 1997 c 203 art 4 s 30-32; 2000 c 400 s 1; 
 1Sp2003 c 14 art 2 s 17