Sec. 10.66.01.03. Civil Money Remedy — Imposition

A. A civil money remedy may be imposed against a provider for violation of a State or federal law governing the conditions of payment for any service or item for which the provider submitted a claim for payment and received payment.

B. It is within the sole discretion of the Inspector General as to whether a civil money remedy is imposed.

C. A civil money remedy may not be imposed if otherwise prohibited by State or federal law.

D. A civil money remedy imposed under this chapter:

(1) Is in lieu of full payment or full adjustment of the paid claim and not in addition to repayment of the claim;

(2) May not be less than the federal financial participation share of the identified improper claim amount unless good cause is shown;

(3) May not exceed the amount of reimbursement that the provider received for the paid claim;

(4) Is only available if the provider has not been subjected to a:

(a) Repayment penalty or fine;

(b) Criminal action; or

(c) Civil false claims action under either federal or State law for the same claim; and

(5) May not be imposed if the claim was included in the universe of claims under an extrapolation calculation.

E. A claim may be made on the basis of more than one violation, but there shall be only one civil money remedy per claim, regardless of the number of violations on which the claim is based.

F. In determining whether a civil money remedy is to be imposed and in setting the amount of the civil money remedy, the Inspector General shall consider:

(1) The number, nature, and seriousness of the violation or violations;

(2) The provider’s history of compliance;

(3) The efforts made by the provider to correct the violations and any continuation of conduct after notification of possible violations;

(4) The provider’s level of cooperation with the Department or Inspector General as it relates to the review of the claim;

(5) The degree of risk to the health, life, or safety of consumers as a result of the violations; and

(6) Any other reasonable factors as fairness may require.

G. The Inspector General shall give special consideration to the extent to which the provider’s size, operations, or financial condition:

(1) May have contributed to the violations; and

(2) May affect the provider’s ability to provide care and continue operations after payment of a civil money remedy.

H. If the civil money remedy is imposed under this chapter, the Inspector General shall issue a written notice and order to the provider that:

(1) States the total amount of the civil money remedies being imposed; and

(2) Includes the following information:

(a) The basis on which the order is made;

(b) Each regulation or statute violated;

(c) The amount of each civil money remedy imposed for each claim;

(d) The number of claims and total value of the claims identified with errors;

(e) The manner in which the amount of the civil money remedy was calculated; and

(f) The provider’s appeal rights.

I. The notice and order shall be sent to the provider by certified mail.