Tenn. Comp. R. & Regs. 1200-13-18-.03 – Administrative Action for Recovery under the Tennessee Medicaid False Claims Act

(1) The Attorney General, following an investigation of an approved provider’s claims, may determine that certain provider actions are appropriate for administrative action by the Bureau, pursuant to the Act. The Attorney General may refer any such matters to the Bureau Director, or his designee, along with the investigative file and a recommendation for action.
(2) The Attorney General shall not refer matters originally brought under T.C.A. § 71-5-183(b) or if any person has the right to participate in or recover from the proceeding pursuant to T.C.A. § 71-5-183(c)(5).
(3) Upon receipt of a written request from the Attorney General, the Bureau may commence a contested case proceeding on behalf of the State for recovery under the Act against any person other than an enrollee, recipient or applicant.
(4) The Bureau may initiate the recovery process by notice of action to the provider setting out:
1. (a) The assessment of damages, civil penalties and related costs;
2. (b) The name and contact information of an individual within the Bureau with knowledge of the claim(s) and the assessment who is authorized to discuss the matter with the provider; and
3. (c) A statement of the right of the provider to appeal the assessment and the manner in which an appeal must be filed.
(5) Any appeal of a notice of action shall be conducted according to rule .01 of this chapter.
(6) The Bureau may recover actual damages in an amount no greater than twenty-five thousand dollars ($25,000). The amount of actual damages may be based upon a statistically valid random sample utilizing a software tool such as RAT-STATS.
(7) In addition to and not limited by the amount of actual damages, the Bureau may recover:
1. (a) Civil penalties of not less than one thousand dollars ($1,000) nor more than five thousand dollars ($5,000) for each claim found to be in violation of the Act;
2. (b) Costs of the administrative action; and
3. (c) Treble the amount of actual damages.
(8) Any action for recovery shall not be brought:
1. (a) More than six (6) years following the date on which the violation of the Act is committed; or
2. (b) More than three (3) years after the date when facts material to the right of action are known or reasonably should have been known by the state official charged with responsibility to act in the circumstances, but in no event not more than ten (10) years after the date the violation was committed, whichever occurs last.
(9) A subpoena issued by an administrative judge pursuant to the APA requiring the attendance of a witness at a hearing may be served by certified mail at any place in the United States.
(10) For purposes of rendering a final order pursuant to the APA, the Bureau is designated as the agency to review initial orders and issue final agency decisions. Orders issued by the Bureau shall have the effect of a final order pursuant to the APA.
(11) Judgment. A final order issued by the Bureau under this rule may be enforced as a final judgment, as follows:
1. (a) A notarized copy of the final order must be filed in the office of the Clerk of the Chancery Court of Davidson County;
2. (b) Upon filing with the Clerk, a final order shall be considered as a judgment by consent of the parties on the same terms and conditions as those recited in the order;
3. (c) The judgment shall be promptly entered by the Court;
4. (d) The judgment shall become final on the date of entry; and
5. (e) A final judgment shall have the same effect, is subject to the same procedures and may be enforced or satisfied in the same manner as any other judgment of a court of record of the State of Tennessee. Statutory Authority: T.C.A. §§ 4-5-202, 71-5-105, 71-5-109 and 71-5-183. Administrative History: Emergency rule filed February 18, 2011; effective through August 17, 2011. Original rule filed May 18, 2011; effective August 16, 2011. Amendment filed January 15, 2013; effective April 15, 2013.