1. A. A provider shall not:

   1. 1. fail to comply with any federal and/or state laws, regulations, policy, or sub-regulatory guidance of the Medicaid program;
   2. 2. fail to comply with the terms or conditions contained in the provider’s enrollment agreement. This includes any enrollment agreement executed with a MCO and any other document executed by or on behalf of the provider setting forth the terms and conditions for participation in the Medicaid program;
   3. 3. fail to notify BHSF, within 10 business days of discovery, of employment or affiliation with an excluded person. If it is determined the failure to disclose this information was intentional, the provider’s enrollment may be voided back to the date of the concealment;

   4. 4. fail to inform BHSF within 10 business days of discovery of any:

      1. a. administrative sanction;
      2. b. criminal charge(s);
      3. c. criminal conviction(s);
      4. d. civil judgement;
      5. e. civil fines; or
      6. f. monetary penalties imposed on the provider;
   5. 5. if it is determined a failure to disclose required information was intentional, the provider's enrollment may be voided back to the effective date of the adverse action.
   6. 6. make a false, fictitious, untrue, or misleading statement, or conceal information, during the application process;
   7. 7. fail to fully disclose all information requested on any form the department or its contractors require for enrollment in the Medicaid program. This includes, but is not limited to, the information required under R.S.46:437;
   8. 8. engage in conduct in violation of an official sanction applied by a licensing authority, professional peer group, or peer review board or organization. The provider shall not continue such conduct following notification by the licensing or reviewing body that said conduct should cease;
   9. 9. employ, contract, or affiliate with any person who has been convicted of a crime related to the provision of services or submission of claims involving the expenditure of public funds. This prohibition includes convictions for an attempt or conspiracy to commit such a crime;

   10. 10. hire, contract with, or affiliate with any person who:

       1. a. has been excluded by the federal government, or any state or territorial government, from a publicly funded healthcare program;
       2. b. has a disqualifying conviction that would prohibit that person or entity from being hired under federal or state law; or
       3. c. has had an adverse action taken against them by a professional licensing or certification entity or board of this or another state that would disqualify the person from providing services a license requires;

   11. 11. have been convicted of a crime of violence or misappropriation of property through fraudulent or exploitive means;

       1. a. this includes any attempt or conspiracy to commit the crime;

       2. b. this prohibition includes, but is not limited to, the following criminal conduct:

          1. i. bribery or extortion;
          2. ii. sale, distribution, or importation of a substance or item prohibited by law;
          3. iii. tax evasion or fraud;
          4. iv. money laundering;
          5. v. securities or exchange fraud;
          6. vi. wire or mail fraud;
          7. vii. violence against a person;
          8. viii. act against the aged, juveniles or infirmed;
          9. ix. any crime involving public funds;
          10. x. identify theft, or
          11. xi. other criminal conduct involving deceit, fraud, or a crime of violence;
   12. 12. violate any settlement agreement with a health oversight agency. This includes any settlement executed pursuant to the Medical Assistance Programs Integrity Law, R.S. 46:437.1 et seq, the Federal False Claims Act, 31 USC 3729 et seq., or any other statutes pertaining to the submissions of false claims to a publicly funded healthcare program;
   13. 13. fail to correct deficiencies listed in a notice of action;
   14. 14. fail to comply with the provisions of a corrective action plan;
   15. 15. engage in any practice prohibited by R.S. 46:438.2, 438.3, 438.4, or the Federal False Claims Act 31 U.S.C. 3729 et seq;
   16. 16. engage in any practice prohibited by any anti-referral statute or regulation similar to the conduct described in 42 USC 1395nn;
   17. 17. fail to repay, or arrange to repay, an overpayment or other erroneous payment within 60 business days of discovery;
   18. 18. fail to pay any administrative or court ordered restitution, damages, criminal or civil fines, monetary penalties, costs of investigation or prosecution, and expenses;
   19. 19. fail to pay any assessed provider fee or payment;
   20. 20. fail to maintain or make available for inspection, audit, or copying records for services provided to Medicaid program recipients for the period under review;
   21. 21. fail to allow BHSF, its contractors or any other health oversight agency to inspect, audit, or copy those records;
   22. 22. fail to produce to BHSF, its contractors or other health oversight agencies, information or documents requested within five business days from receipt of the request unless an extension is granted;

   23. 23. fail to cooperate with BHSF, its contractors, or any other health oversight agency during a claims review or investigative process, including any informal hearing, administrative appeal, or other legal process;

       1. a. the exercising of a constitutional or statutory right is not a failure to cooperate;
       2. b. requests for scheduling changes or asking questions are not grounds for failure to cooperate;
   24. 24. make, or cause to be made, a false or misleading statement in connection with a claims review or investigation. This includes any informal hearing, administrative appeal, or other legal process;

   25. 25. knowingly make, or cause to be made, a false, fictitious or misleading statement of material fact in connection with the administration of the Medicaid program. This includes, but is not limited to, the following:

       1. a. claiming costs for non-covered or non-chargeable services disguised as covered items;
       2. b. billing for services provided to person(s) who are ineligible to receive the services;
       3. c. misrepresenting dates, descriptions, or the identity of the person(s) who rendered the services;
       4. d. submitting duplicate claims for services for which the provider has already received payment;
       5. e. up-coding services provided;
       6. f. misrepresenting a recipient's need or eligibility to receive services;
       7. g. unbundling services for billing purposes;
       8. h. misrepresenting the quality or quantity of services claimed;
       9. i. knowingly submitting claims for services provided to persons not eligible to receive the service when the service was provided;
       10. j. furnishing or causing to be furnished medically unnecessary, grossly inadequate, or unauthorized services;
       11. k. providing services in a manner or form not within the normal scope and range of the standards used in the applicable profession; or
       12. l. billing for services in a manner inconsistent with the standards established in relevant billing codes or practices;
   26. 26. fail to provide all medically necessary services needed by a recipient and to which the recipient is entitled when operating as a managed care provider or under a voucher;
   27. 27. submit claims to the Medicaid program on behalf of an excluded person;
   28. 28. submit claims to the Medicaid program for services an excluded person provided, either in whole or in part;
   29. 29. engage in a systematic abusive or fraudulent billing practice that maximize costs to the Medicaid program;
   30. 30. engage in any physical abuse, neglect, or exploitation of any recipient receiving services from the provider; and
   31. 31. fail to meet the terms of an agreement entered into under this state's Medical Assistance Program Integrity Law or this regulation.
2. B. Any provider who engages in conduct this section prohibits shall be subject to any of the sanctions allowed by law and this Chapter.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and 46:437.1-46:440.3.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Health, Bureau of Health Services Financing, LR 52:693 (May 2026).