(a) Definitions.  The following words and terms, when used in this Section, have the following meaning, unless the context clearly indicates otherwise.

• (1) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.  It also recognizes recipient practices that result in unnecessary cost to the Medicaid program.
• (2) "Conviction" or "Convicted" means a judgment of conviction has been entered by a Federal, State, or local court, regardless of whether an appeal from that judgment is pending.
• (3) "Exclusion" means items or services which will not be reimbursed under Medicaid because they were furnished by a specific provider who has defrauded or abused the Medicaid program.
• (4) "Fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.  It includes any act that constitutes fraud under applicable Federal or State law.
• (5) "Knowingly" means that a person, with respect to information:
  • (A) has actual knowledge of the information;
  • (B) acts in deliberate ignorance of the truth or falsity of the information; or
  • (C) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required.
• (6) "Medical Services Providers" means:
  • (A) "Practitioner" means a physician or other individual licensed under State law to practice his or her profession or a physician who meets all requirement for employment by the Federal Government as a physician and is employed by the Federal Government in an IHS facility  or affiliated with a 638 Tribal facility.
  • (B) "Supplier" means an individual or entity, other than a provider or practitioner, who furnishes health care services under Medicaid or other medical services programs administered by the Oklahoma Health Care Authority.
  • (C) "Provider" means:
    • (i) A hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, or a hospice that has in effect an agreement to participate in Medicaid, or any other medical services program administered by the Oklahoma Health Care Authority, or
    • (ii) a clinic, a rehabilitation agency, or a public health agency that has a similar agreement.
  • (D) "Laboratories" means any laboratory or place equipped for experimental study in science or for testing or analysis which has an agreement with the Oklahoma Health Care Authority to receive Medicaid monies.
  • (E) "Pharmacy" means any pharmacy or place where medicines are compounded or dispensed or any pharmacist who has an agreement with OHCA to receive Medicaid monies for the dispensing of drugs.
  • (F) "Any other provider" means any provider who has an agreement with OHCA to deliver health services, medicines, or medical services for the receipt of Medicaid monies.
• (7) "OIG" means Office of Inspector General of the Department of Health and Human Services.
• (8) "Sanctions" means any administrative decision by OHCA to suspend or exclude a medical service provider(s) from the Medicaid program or any other medical services program administered by the Oklahoma Health Care Authority.
• (9) "Suspension" means items or services furnished by a specified provider will not be reimbursed under the Medicaid program.
• (10) "Willfully" means proceeding from a conscious motion of the will; voluntary, intending the result which comes to pass; intentional.

(b) Basis for sanctions.

• (1) The Oklahoma Health Care Authority may sanction a medical provider who has an agreement with OHCA for the following reasons:
  • (A) Knowingly or willfully made or caused to be made any false statement or misrepresentation of material fact in claiming, or use in determining the right to, payment under Medicaid; or
  • (B) Furnished or ordered services under Medicaid that are substantially in excess of the recipient's needs or that fail to meet professionally recognized standards for health care; or
  • (C) Submitted or caused to be submitted to the Medicaid program bills or requests for payment containing charges or costs that are substantially in excess of customary charges or costs.  However, the agency must not impose an exclusion under this section if it finds the excess charges are justified by unusual circumstances or medical complications requiring additional time, effort, or expense in localities in which it is accepted medical practice to make an extra charge in such case.
• (2) The agency may base its determination that services were excessive or of unacceptable quality on reports, including sanction reports, from any of the following sources:
  • (A) The PRO for the area served by the provider or the PRO contracted by OHCA;
  • (B) State or local licensing or certification authorities;
  • (C) Peer review committees of fiscal agents or contractors;
  • (D) State or local professional societies;
  • (E) Surveillance and Utilization Review Section Reports done by OHCA; or
  • (F) Other sources deemed appropriate by the Medicaid agency or the OIG.
• (3) OHCA must suspend from the Medicaid program any medical services provider who has been suspended from participation in Medicare or Medicaid due to a conviction of a program related crime.  This suspension must be at a minimum the same period as the Medicare suspension.
• (4) OHCA must also suspend any convicted medical services provider who is not eligible to participate in Medicare or Medicaid whenever the OIG directs such action.  Such suspension must be, at a minimum, the same period as the suspension by the OIG.

(c) Procedure for imposing sanctions.  The procedure for imposing a sanction under this section and the due process accorded in this section is provided at OAC 317:2-1-5.