(1) Pursuant to the authority granted by T.C.A. § 71-5-118 to the Commissioner to impose sanctions against providers, the Commissioner, through the Bureau, may take the following actions against a provider upon a finding that such actions will further the purpose of the Tennessee Medical Assistance Act:

1. (a) Subject providers to stringent review and audit procedures which may include clinical evaluation of claim services and a prepayment requirement for documentation and for justification of each claim;
2. (b) Refuse to issue or terminate a Tennessee Medicaid Provider Number if any person who has an ownership or controlling interest in the provider, or who is an agent or managing employee of the provider, has been convicted of a criminal offense related to that person’s involvement in any program established under Medicare, Medicaid or the U.S. Title XX Services Program;
3. (c) Refuse to issue or terminate a Tennessee Medicaid Provider Number if a determination is made that the provider did not fully and accurately make any disclosure of any person who has ownership or controlling interest in the provider, or is an agent or managing employee of the provider and has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or the U.S. Title XX Services Program since the inception of these programs;
4. (d) Refuse to issue or terminate a Tennessee Medicaid Provider Number if the appropriate State Board of Licensing or Certification fails to license or certify the provider at any time for any reason or suspends or revokes a license or certification;
5. (e) Refuse to issue or terminate a Tennessee Medicaid Provider Number upon notification by the U.S. Office of Inspector General Department of Health and Human Services that the provider is not eligible under Medicare or Medicaid for federal financial participation;
6. (f) Suspend or withhold payments to a provider in cases of fraud, willful misrepresentation, or flagrant noncompliance; or,
7. (g) Recover from a provider any payments made by a recipient and/or his family for a covered service when evidence of recipient billing by the provider is determined by the Bureau and repayment by the provider to the recipient and/or his family is not made within 30 days of receiving notification from the Bureau to make repayment. If a provider knowingly bills a recipient and/or family for a TennCare covered service, in total or in part, except as otherwise permitted by State rules, the Bureau may terminate the provider from participation in the program.

(2) In addition to the grounds for sanctions set out in T.C.A. § 71-5-118, activities or practices which justify sanctions against a provider and may include recoupment of monies incorrectly paid shall include but not be limited to:

1. (a) Noncompliance with contractual terms;
2. (b) Billing for a service in a quantity which is greater than the amount provided;
3. (c) Billing for a service which is not provided or not documented;
4. (d) Knowingly providing incomplete, inaccurate, or erroneous information to TennCare or its agent(s);
5. (e) Continued provision of poor record keeping or inappropriate or inadequate medical care;
6. (f) Medical assistance of a quality below recognized standards;
7. (g) Suspension from the Medicare or Medicaid program(s) by the authorized U.S. enforcement agency;
8. (h) Partial or total loss (voluntary or otherwise) of a provider’s federal Drug Enforcement Agency (DEA) dispensing or prescribing certification;
9. (i) Restriction to or loss of practice by a state licensing board action;
10. (j) Acceptance of a pretrial diversion, in state or federal court, from a Medicaid or Medicare fraud charge or evidence from such charge;
11. (k) Violation of the responsible state licensing board license or certification rules;
12. (l) Conviction of any felony, any offense under state or federal drug laws, or any offense involving moral turpitude;
13. (m) Dispensing, prescribing, or otherwise distributing any controlled substance or any other drug not in the course of professional practice, or not in good faith to relieve pain and suffering, or not to cure an ailment, physical or mental infirmity or disease;
14. (n) Dispensing, prescribing, or otherwise distributing to any person a controlled substance or other drug if such person is addicted to the habit of using controlled substances without making a bona fide effort to cure the habit of such patient;
15. (o) Dispensing, prescribing or otherwise distributing any controlled substance or other drug to any person in violation of any law of the state or of the United States of America;
16. (p) Engaging in the provision of medical or dental service when mentally or physically unable to safely do so;
17. (q) Billing TennCare an amount that is greater than the provider’s usual and customary charge to the general public for that service;
18. (r) Falsifying or causing to be falsified dates of service, dates of certification or recertification or back dating any record which results in or could result in an inappropriate cost to TennCare;
19. (s) Fragmentation or submitting claims separately on the component parts of a procedure instead of claiming a single procedure code which includes the entire procedure or all component parts, when such approach results in TennCare paying a greater amount for the components than it would for the entire procedure; or,
20. (t) Submitting claims for a separate procedure which is commonly carried out as a component part of a larger procedure, unless it is performed alone for a medically justified specific purpose. Statutory Authority: T.C.A. §§ 4-5-202, 71-5-105 and 71-5-109. Administrative History: Original rule filed May 18, 2011; effective August 16, 2011.