Louisiana Revised Statutes 46:437.4 – Claims review and administrative sanctions
Terms Used In Louisiana Revised Statutes 46:437.4
- Claim: means any request or demand, whether under a contract or otherwise, for money or property, whether or not the state or department has title to the money or property, that is drawn in whole or in part on medical assistance programs funds that are either of the following:
(a) Presented to an officer, employee, or agent of the state or department. See Louisiana Revised Statutes 46:437.3
- Department: means the Louisiana Department of Health. See Louisiana Revised Statutes 46:437.3
- Health care provider: means any person furnishing or claiming to furnish a good, service, or supply under the medical assistance programs, any other person defined as a health care provider by federal or state law or by rule, and a provider-in-fact. See Louisiana Revised Statutes 46:437.3
- Medical assistance programs: means the Medical Assistance Program (Title XIX of the Social Security Act), commonly referred to as "Medicaid" and other programs operated by and funded in the department which provide payment to health care providers. See Louisiana Revised Statutes 46:437.3
- Order: means a final order imposed pursuant to an administrative adjudication. See Louisiana Revised Statutes 46:437.3
- Payment: means the payment to a health care provider from medical assistance programs funds pursuant to a claim, or the attempt to seek payment for a claim. See Louisiana Revised Statutes 46:437.3
- person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
- Rule: means any rule or regulation promulgated by the department in accordance with the Administrative Procedure Act and any federal rule or regulation promulgated by the federal government in accordance with federal law. See Louisiana Revised Statutes 46:437.3
- Sanction: shall include but is not limited to any or all of the following:
(a) Recoupment. See Louisiana Revised Statutes 46:437.3
- Secretary: means the secretary of the Louisiana Department of Health, or his authorized designee. See Louisiana Revised Statutes 46:437.3
- Withhold payment: means to reduce or adjust the amount, in whole or in part, to be paid to a health care provider for a pending or future claim during the time of a criminal, civil, or departmental investigation or proceeding or claims review of the health care provider. See Louisiana Revised Statutes 46:437.3
A.(1) Pursuant to rules and regulations promulgated in accordance with the Administrative Procedure Act, the secretary shall establish a process to review a claim made by a health care provider to determine if the claim should be or should have been paid as required by federal or state law or by rule.
(2) Claims review may occur prior to or after payment is made to a health care provider.
(3) The secretary may withhold payment to a health care provider during claims review if necessary to protect the fiscal integrity of the medical assistance programs.
(4) The administrative rules promulgated by the department to implement the claim review process established pursuant to this Subsection shall provide for procedures to ensure that providers receive or retain the appropriate reimbursement amount for claims in which the department determines that services delivered have been improperly billed but were reasonable and necessary.
B. The secretary may establish various types of administrative sanctions pursuant to rules and regulations promulgated in accordance with the Administrative Procedure Act which may be imposed on a health care provider or other person who violates any provision of this Part or any other applicable federal or state law or rule related to the medical assistance programs.
C.(1) The department shall conduct a hearing in compliance with the Administrative Procedure Act at the request of a person who wishes to contest an administrative sanction imposed on him by the secretary.
(2) A party aggrieved of an order may seek judicial review only in the Nineteenth Judicial District Court for the parish of East Baton Rouge.
(3) Judicial review of the order shall be conducted in compliance with the Administrative Procedure Act.
D. All state rules and regulations issued on or before August 15, 1997, shall be deemed to have been issued in compliance with and under the authority of this Section.
Acts 1997, No. 1373, §1; Acts 2016, No. 467, §1.