Section 106.06. Involuntary termination or suspension from program participation.

  The department may suspend or terminate the certification of any person, partnership, corporation, association, agency, institution or other entity participating as a health care provider under the program, if the suspension or termination will not deny recipients access to MA services and if after reasonable notice and opportunity for a hearing the department finds that:

(1)   Non-compliance with MA requirements. The provider has repeatedly and knowingly failed or refused to comply with federal or state statutes, rules or regulations applicable to the delivery of, or billing for, services under the program;

(2)   Refusal to comply with provider agreement. The provider has repeatedly and knowingly failed or refused to comply with the terms and conditions of its provider agreement;

(3)   Improper activities.

(a) The provider has prescribed, provided, or claimed reimbursement for services under the program which were:

1. Inappropriate;

2. Unnecessary or in excess of the recipient's needs;

3. Detrimental to the health and safety of the recipient; or

4. Of grossly inferior quality.

(b) Findings precipitating action by the department under this subsection shall be based on the written findings of a peer review committee established by the department or a PRO under contract to the department to review and evaluate health care services provided under the program. The findings shall be presumptive evidence that the provider has engaged in improper activities under this subsection.

(4)   Suspension or revocation. The licensure, certification, authorization or other official entitlement required as a prerequisite to the provider's certification to participate in the program has been suspended, restricted, terminated, expired or revoked;

(4m)  In the case of a freestanding personal care agency as defined in s. DHS 105.17 (1) (a) , the freestanding personal care agency has violated one or more of the applicable requirements of ch. DHS 105 in a manner or to a degree that may endanger or threaten the health or safety of clients, has not paid the fee, or has failed to provide information requested by the department in connection with certification;

(5)   Public health in jeopardy. A provider's licensure, certification, authorization or other official entitlement has been suspended, terminated, expired or revoked under state or federal law following a determination that the health, safety or welfare of the public is in jeopardy;

(6)   Medicare sanctions.

(a) The provider is excluded or terminated from the medicare program or otherwise sanctioned by the medicare program because of fraud or abuse of the medicare program under 42 CFR 420.101 or 474.10 .

(b) The provider is suspended from the medicare program for conviction of a medicare program-related crime under 42 CFR 420.122 .

(c) The provider is a party convicted of a crime, ineligible to participate in the medicare program and the health care financing administration directs the department to suspend the provider;

(7)   Service during period of noncertification. The provider has provided a service to a recipient during a period in which provider's licensure, certification, authorization, or other entitlement to provide the service was terminated, suspended, expired or revoked;

(8)   Criminal conviction. The provider has been convicted of a criminal offense related to providing or claiming reimbursement for services under medicare or under this or any other state's MA program. In this subsection, "convicted" means that a judgment of conviction has been entered by a federal, state or local court, irrespective of whether an appeal from that judgment is pending;

(9)   False statements. The provider knowingly made or caused to be made a false statement or misrepresentation of material fact in connection with provider's application for certification or recertification;

(10)   Failure to report status change. The provider has concealed, failed or refused to disclose any material change in licensure, certification, authorization, or ownership which, if known to the department, would have precluded the provider from being certified;

(11)   Concealment of outside controlling interests. The provider at the time of application for certification under ch. DHS 105 or after receiving that certification knowingly misrepresented, concealed or failed to disclose to the department full and complete information as to the identity of each person holding an ownership or controlling interest in the provider;

(12)   Concealment of provider's controlling interests. The provider at the time of application for certification under ch. DHS 105 or after receiving that certification knowingly misrepresented, concealed or failed to disclose to the department an ownership or controlling interest the provider held in a corporation, partnership, sole proprietorship or other entity certified under the program;

(13)   False statements concerning the nature and scope of services. The provider made or caused to be made false statements or misrepresentation of material facts in records required under s. DHS 105.02 (4) , (6) or (7) and maintained by the provider for purposes of identifying the nature and scope of services provided under the program;

(14)   False statements concerning the costs of services. The provider has knowingly made or caused to be made false statements or has misrepresented material facts in connection with the provider's usual and customary charges submitted to the department as a claim for reimbursement;

(15)   False statements concerning cost reports. The provider has knowingly made or caused to be made false statements or misrepresentation of material facts in cost reports relating to the provider's costs, expenditures or usual and customary charges submitted to the department for the purpose of establishing reimbursement rates under the program;

(16)   Failure to keep records. The provider has failed or refused to prepare, maintain or make available for inspection, audit or copy by persons authorized by the department, records necessary to fully disclose the nature, scope and need of services provided recipients;

(17)   False statement on claim. The provider has knowingly made or caused to be made a false statement or misrepresentation of a material fact in a claim;

(18)   Obstruction of investigation. The provider has intentionally by act of omission or commission obstructed an investigation or audit being conducted by authorized departmental personnel pursuant to s. 49.45 (3) (g) , Stats.;

(19)   Payment for referral. The provider has offered or paid to another person, or solicited or received from another person, any remuneration in cash or in kind in consideration for a referral of a recipient for the purpose of procuring the opportunity to provide covered services to the recipient, payment for which may be made in whole or in part under the program;

(20)   Failure to request copayments. The provider has failed to request from recipients the required copayment, deductible or coinsurance amount applicable to the service provided to recipients after having received a written statement from the department noting the provider's repeated failure to request required copayments, deductible or coinsurance amounts and indicating the intent to impose a sanction if the provider continues to fail to make these requests;

(21)   Charging recipient. The provider has, in addition to claiming reimbursement for services provided a recipient, imposed a charge on the recipient for the services or has attempted to obtain payment from the recipient in lieu of claiming reimbursement through the program contrary to provisions of s. DHS 106.04 (3) ;

(22)   Racial or ethnic discrimination. The provider has refused to provide or has denied services to recipients on the basis of the recipient's race, color or national origin in violation of the civil rights act of 1964, as amended, 42 USC 200d , et. seq., and the implementing regulations, 45 CFR Part 80 ;

(23)   Handicapped discrimination. The provider has refused to provide or has denied services to a handicapped recipient solely on the basis of handicap, thereby violating section 504 of the rehabilitation act of 1973, as amended, 29 USC 794 ;

(24)   Funds mismanagement. A provider providing skilled nursing or intermediate care services has failed to or has refused to establish and maintain an accounting system which ensures full and complete accounting of the personal funds of residents who are recipients, or has engaged in, caused, or condoned serious mismanagement or misappropriation of the funds;

(25)   Refusal to repay erroneous payments. The provider has failed to repay or has refused to repay amounts that have been determined to be owed the department either under s. DHS 106.04 (5) or pursuant to a judgment of a court of competent jurisdiction, as a result of erroneous or improper payments made to the provider under the program;

(26)   Faulty submission of claims, failure to heed MA billing standards, or submission of inaccurate billing information. The provider has created substantial extraordinary processing costs by submitting MA claims for services that the provider knows, or should have known, are not reimbursable by MA, MA claims which fail to provide correct or complete information necessary for timely and accurate claims processing and payment in accordance with proper billing instructions published by the department or the fiscal agent, or MA claims which include procedure codes or procedure descriptions that are inconsistent with the nature, level or amount of health care provided to the recipient, and, in addition, the provider has failed to reimburse the department for extraordinary processing costs attributable to these practices;

(27)   Refusal to purge contempt order. The provider failed or refused to purge a contempt order issued under s. 885.12 , Stats., as a result of the provider's refusal to obey a subpoena under s. 49.45 (3) (h) 1. , Stats.;

(28)   Other termination reasons. The provider, a person with management responsibility for the provider, an officer or person owning directly or indirectly 5% or more of the shares or other evidences of ownership of a corporate provider, a partner in a partnership which is a provider, or the owner of a sole proprietorship which is a provider, was:

(a) Terminated from participation in the program within the preceding 5 years;

(b) A person with management responsibility for a provider previously terminated under this section, or a person who was employed by a previously terminated provider at the time during which the act or acts occurred which served as the basis for the termination of the provider's program anticipation and knowingly caused, concealed, performed or condoned those acts;

(c) An officer of or person owning, either directly or indirectly, 5% of the stock or other evidences of ownership in a corporate provider previously terminated at the time during which the act or acts occurred which served as the basis for the termination;

(d) An owner of a sole proprietorship or a partner in a partnership that was terminated as a provider under this section, and the person was the owner or a partner at the time during which the act or acts occurred which served as the basis for the termination;

(e) Convicted of a criminal offense related to the provision of services or claiming of reimbursement for services under medicare or under this or any other state's medical assistance program. In this subsection, "convicted" means that a judgment of conviction has been entered by a federal, state or local court, irrespective of whether an appeal from the judgment is pending;

(f) Excluded, terminated, suspended or otherwise sanctioned by medicare or by this or any other state's medical assistance program; or

(g) Barred from participation in medicare by the federal department of health and human services, and the secretary of the federal department of health and human services has directed the department to exclude the individual or entity from participating in the MA program under the authority of section 1128 or 1128A of the social security act of 1935, as amended.

(29)   Billing for services of a non-certified provider. The provider submitted claims for services provided by an individual whose MA certification had been terminated or suspended, and the submitting provider had knowledge of the individual's termination or suspension; or

(30)   Business transfer liability. The provider has failed to comply with the requirements of s. 49.45 (21) , Stats., regarding liability for repayment of overpayments in cases of business transfer.

History: Cr. Register, December, 1979, No. 288 , eff. 2-1-80; am. Register, February, 1986, No. 362 , eff. 3-1-86; emerg. am. (28) (e) and (f), cr. (28) (g), eff. 2-19-88; am. (28) (e) and (f), cr. (28) (g), Register, August, 1988, No. 392 , eff. 9-1-88; correction in (25) made under s. 13.93 (2m) (b) 7., Stats., Register February 2002 No. 554 ; corrections in (11), (12) and (13) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636 ; CR 09-107 : cr. (4m) Register August 2010 No. 656 , eff. 9-1-10.

Note

See s. 49.45 (18) , Stats., and s. DHS 106.04 (2) for requirements on copayments, deductibles and coinsurance amounts. Microsoft Windows NT 6.1.7601 Service Pack 1 See s. DHS 107.09 (4) (i) for requirements concerning accounting for the personal funds of nursing home residents. Microsoft Windows NT 6.1.7601 Service Pack 1 2001 Wis. Act 16 repealed s. 49.45 (3) (h) 1., Stats. Microsoft Windows NT 6.1.7601 Service Pack 1