208.164. Medical assistance abuse or fraud, definitions--department's or division's powers--reports, confidential--restriction or termination of benefits, when--rules.
Medical assistance abuse or fraud, definitions--department's ordivision's powers--reports, confidential--restriction or terminationof benefits, when--rules.
208.164. 1. As used in this section, unless the context clearlyrequires otherwise, the following terms mean:
(1) "Abuse", a documented pattern of inducing, furnishing, or otherwisecausing a recipient to receive services or merchandise not otherwise requiredor requested by the recipient, attending physician or appropriate utilizationreview team; a documented pattern of performing and billing tests,examinations, patient visits, surgeries, drugs or merchandise that exceedlimits or frequencies determined by the department for like practitioners forwhich there is no demonstrable need, or for which the provider has created theneed through ineffective services or merchandise previously rendered. Thedecision to impose any of the sanctions authorized in this section shall bemade by the director of the department, following a determination ofdemonstrable need or accepted medical practice made in consultation withmedical or other health care professionals, or qualified peer review teams;
(2) "Department", the department of social services;
(3) "Excessive use", the act, by a person eligible for services under acontract or provider agreement between the department of social services orits divisions and a provider, of seeking and/or obtaining medical assistancebenefits from a number of like providers and in quantities which exceed thelevels that are considered medically necessary by current medical practicesand standards for the eligible person's needs;
(4) "Fraud", a known false representation, including the concealment ofa material fact that provider knew or should have known through the usualconduct of his profession or occupation, upon which the provider claimsreimbursement under the terms and conditions of a contract or provideragreement and the policies pertaining to such contract or provider agreementof the department or its divisions in carrying out the providing of services,or under any approved state plan authorized by the federal Social SecurityAct;
(5) "Health plan", a group of services provided to recipients of medicalassistance benefits by providers under a contract with the department;
(6) "Medical assistance benefits", those benefits authorized to beprovided by sections 208.152 and 208.162;
(7) "Prior authorization", approval to a provider to perform a serviceor services for an eligible person required by the department or its divisionsin advance of the actual service being provided or approved for a recipient toreceive a service or services from a provider, required by the department orits designated division in advance of the actual service or services beingreceived;
(8) "Provider", any person, partnership, corporation, not-for-profitcorporation, professional corporation, or other business entity that entersinto a contract or provider agreement with the department or its divisions forthe purpose of providing services to eligible persons, and obtaining from thedepartment or its divisions reimbursement therefor;
(9) "Recipient", a person who is eligible to receive medical assistancebenefits allocated through the department;
(10) "Service", the specific function, act, successive acts, benefits,continuing benefits, requested by an eligible person or provided by theprovider under contract with the department or its divisions.
2. The department or its divisions shall have the authority to suspend,revoke, or cancel any contract or provider agreement or refuse to enter into anew contract or provider agreement with any provider where it is determinedthe provider has committed or allowed its agents, servants, or employees tocommit acts defined as abuse or fraud in this section.
3. The department or its divisions shall have the authority to imposeprior authorization as defined in this section:
(1) When it has reasonable cause to believe a provider or recipient hasknowingly followed a course of conduct which is defined as abuse or fraud orexcessive use by this section; or
(2) When it determines by rule that prior authorization is reasonablefor a specified service or procedure.
4. If a provider or recipient reports to the department or its divisionsthe name or names of providers or recipients who, based upon their personalknowledge has reasonable cause to believe an act or acts are being committedwhich are defined as abuse, fraud or excessive use by this section, suchreport shall be confidential and the reporter's name shall not be divulged toanyone by the department or any of its divisions, except at a judicialproceeding upon a proper protective order being entered by the court.
5. Payments for services under any contract or provider agreementbetween the department or its divisions and a provider may be withheld by thedepartment or its divisions from the provider for acts or omissions defined asabuse or fraud by this section, until such time as an agreement between theparties is reached or the dispute is adjudicated under the laws of this state.
6. The department or its designated division shall have the authority toreview all cases and claim records for any recipient of public assistancebenefits and to determine from these records if the recipient has, as definedin this section, committed excessive use of such services by seeking orobtaining services from a number of like providers of services and inquantities which exceed the levels considered necessary by current medical orhealth care professional practice standards and policies of the program.
7. The department or its designated division shall have the authoritywith respect to recipients of medical assistance benefits who have committedexcessive use to limit or restrict the use of the recipient's Medicaididentification card to designated providers and for designated services; theactual method by which such restrictions are imposed shall be at thediscretion of the department of social services or its designated division.
8. The department or its designated division shall have the authoritywith respect to any recipient of medical assistance benefits whose use hasbeen restricted under subsection 7 of this section and who obtains or seeks toobtain medical assistance benefits from a provider other than one of theproviders for designated services to terminate medical assistance benefits asdefined by this chapter, where allowed by the provisions of the federal SocialSecurity Act.
9. The department or its designated division shall have the authoritywith respect to any provider who knowingly allows a recipient to violatesubsection 7 of this section or who fails to report a known violation ofsubsection 7 of this section to the department of social services or itsdesignated division to terminate or otherwise sanction such provider's statusas a participant in the medical assistance program. Any person making such areport shall not be civilly liable when the report is made in good faith.
(L. 1982 H.B. 1086 § 1, A.L. 1995 S.B. 3)CROSS REFERENCE:
Health care assistance payments fraud and abuse, RSMo 191.900 to 191.910