Louisiana Revised Statutes 46:437.13 – Powers and duties of the department
Terms Used In Louisiana Revised Statutes 46:437.13
- Agent: means a person who is employed by or has a contractual relationship with a health care provider or who acts on behalf of the health care provider. See Louisiana Revised Statutes 46:437.3
- 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
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
- 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
- Ownership interest: means the possession, directly or indirectly, of equity in the capital or the stock, or the right to share in the profits, of a health care provider. 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
- Provider agreement: means a document which is required as a condition of enrollment or participation as a health care provider under the medical assistance programs. See Louisiana Revised Statutes 46:437.3
- Recipient: means an individual who is eligible to receive health care through the medical assistance programs. See Louisiana Revised Statutes 46:437.3
- 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
A. The department shall:
(1) Make payment timely at the established rate for goods, services, or supplies furnished to a recipient by the health care provider upon receipt of a properly completed and properly supported claim.
(2) Require certification on the claim form that the goods, services, or supplies have been completely furnished to a recipient eligible to receive the goods, services, or supplies and that, with the exception of those goods, services, or supplies specified by the department, the amount billed does not exceed the health care provider’s usual and customary charge for the same goods, services, or supplies.
(3) Not demand repayment from the health care provider in any instance in which the medical assistance programs overpayment is attributable to error of the department in the determination of eligibility of a recipient.
B. The department may:
(1) Adopt, and include in the provider agreement, such other requirements and stipulations on either party as the department finds necessary to properly and efficiently administer the medical assistance programs.
(2)(a) Revoke any provider agreement as the result of a change of ownership in the named health care provider.
(b) Require a health care provider to give the department sixty days written notice before making any change in ownership of the person named in the provider agreement as the health care provider.
(3) Require, as a condition of participating in the medical assistance programs and before entering into the provider agreement, the following:
(a) An on-site inspection of the health care provider’s service location by department representatives or other personnel designated by the secretary to assist in this function.
(b) A letter of credit, a surety bond, or a combination thereof, from the health care provider not to exceed fifty thousand dollars. The letter of credit, surety bond, or combination thereof may be required only if either of the following conditions is met:
(i) A letter of credit, surety bond, or any combination thereof is required for each health care provider in that category of health care provider.
(ii) The health care provider is the subject of a sanction or of a criminal, civil, or departmental proceeding.
(c) The submission of information concerning the professional, business, and personal background of the health care provider, any person having an ownership interest in the health care provider, and any agent of the health care provider. Such information shall include:
(i) Proof of holding a valid license or operating certificate, as applicable, if required by federal or state law or by rule or by a local jurisdiction in which the health care provider is located.
(ii) Any prior violation, fine, suspension, termination, or other administrative action taken under federal or state law or rule or the laws or rules of any other state relative to medical assistance programs, Medicare, or a regulatory body.
(iii) Any prior violation of the rules or regulations of any other public or private insurer.
(iv) Full and accurate disclosure of any financial or ownership interest that the health care provider, or a person with an ownership interest in that health care provider, may hold in any other health care provider or health care related entity or any other entity that is licensed by the state to provide health or residential care and treatment to persons.
(v) If a group health care provider, identification of all members of the group and attestation that all members of the group are enrolled in or have applied to enroll in the medical assistance programs.
C. Upon receipt of a completed, signed, and dated application, and after any necessary investigation by the department, which may include the Department of Public Safety and Corrections, office of state police background checks, the department shall either:
(1) Enroll the applicant as a Medicaid provider.
(2) Deny the application if, based on the grounds listed in La. Rev. Stat. 46:437.14, the secretary determines that it is in the best interest of the medical assistance programs to do so, specifying the reasons for denial.
D. In accordance with the provisions of 42 C.F.R. § 433.318(d)(2)(ii), the department is hereby granted the authority to certify that a provider enrolled in the Medical Assistance Program is out of business and that any overpayments made to the provider cannot be collected under state law.
Acts 1997, No. 1142, §2; Acts 2008, No. 139, §1.