4123-6-02.7 Provider access to the HPP - provider decertification procedures.

 

 

 

4123-6-02.7                 Provider    access     to    the    HPP    -    provider                   decertification procedures.

 

 

 

(A)   Except as otherwise provided in paragraph (C) of this rule, the administrator ofthe bureau of workers' compensation shall follow the procedures set forth in this rule to terminate the enrollment of and decertify an individual a non-facility provider who has failed to comply with a workers' compensation statute or rule, or a term of the provider application and agreement or recertification application and agreement.

 

(1)    If the bureau determines a provider has committed three or more reported violations of the same workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement in a six month period, or five or more reported violations of any workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement in a six month period, the bureau shall send the provider shall receive written notification from the bureau of the violations by certified mail.

 

(2)   If the bureau determines the provider has committed two or more subsequent reported violations of any workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement for which the provider previously received notice pursuant to paragraph (A)(1) of this rule, and the subsequent violations occurred any time within the twelve month period following the calendar month in which the provider received notice pursuant to paragraph (A)(1) of this rule, the bureau shall send the provider shall receive written notification from the bureau of the violations by certified mail, which shall include a thirty day implementation period for within which the provider to must submit and implement a correction plan to the bureau and correct the behavior. The correction plan shall be entered into the provider's certification file and the provider's certification file shall have the notation "under correction plan" during the twelve month period following the calendar month in which the provider's thirty day implementation period provided above expires.

 

If  the  provider  fails  to  submit  a  correction  plan  within  the  thirty  day implementation period satisfactory to the bureau, which satisfaction shall not

be unreasonably withheld, the bureau shall send

the provider shall receive

written notification from the bureau of the failure by certified mail, which shall include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(3)   If the bureau determines the provider has committed two or more subsequent reported violations of the same workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement  for  which  the  provider  previously  received  notice  pursuant  to

paragraph (A)(2) of this rule and submitted a correction plan satisfactory to the bureau, and the subsequent violations occurred any time within the twelve month period following the calendar month in which the provider's thirty day implementation period provided in the notice sent pursuant to paragraph (A)(2) of this rule expires, the bureau shall send the provider shall receive written notification from the bureau of the violations by certified mail, which shall include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(4)     If the bureau determines a provider who has twice received written notice pursuant to paragraph (A)(1) of this rule for violation of the same workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement has committed a subsequent reported violation of the same workers' compensation statute or rule, or term of the provider application and agreement or recertification application and agreement within three years of the date written notification was first sent to the provider by the bureau pursuant to paragraph (A) of this rule, the bureau shall send the provider shall receive written notification from the bureau of the violation by certified mail, which shall include a notice of proposed enrollment termination and decertification complying with rule 4123-6-17 of the Administrative Code.

(5)      The bureau may, in its discretion, waive strict may consider mitigating circumstances in its application of the procedures set forth in paragraphs (A)(1) to (A)(4) of this rule with regard to an individual provider based on the presence of mitigating. Mitigating circumstances, which may include, but are not limited to:

(a)   The violations related to the provision of emergency treatment;

(b)   At the time the violations occurred, the provider was not aware a workers' compensation claim was involved;

(c)   The provider was initially bureau certified within six months prior to the violations;

(d)  The violations were due to bureau or MCO error;

(e)    The provider billed the bureau for goods or services in fewer than five workers workers' compensation claims in the twelve months prior to the violations;

(f)  Other documented justification as deemed sufficient by the bureau.

(6) If any notice sent by certified mail pursuant to this rule is returned because the party fails to claim the notice, the bureau shall resend the notice by ordinary mail to the party at the party's last known address appearing in the bureau's records and shall obtain a certificate of mailing.

(B)     Providers whose enrollment is terminated and who are decertified pursuant to paragraph (A)(3) or (A)(4) of this rule shall be eligible to apply for and be considered for recertification and reenrollment at any time after two years from the date of the final administrative or judicial order of enrollment termination and decertification.

(C)    The procedures set forth in paragraphs (A)(1) to (A)(5) (A)(6) of this rule do not apply to, and the administrator may proceed directly to enrollment termination and/or decertification of a provider for, violation of the following:

(1)     The minimum provider credentialing certification criteria set forth in rule 4123-6-02.2 of the Administrative Code.

(2)   Acts of misrepresentation, misstatement, or omission of a relevant fact or other acts involving dishonesty, fraud, or deceit on the provider's provider application and agreement or recertification application and agreement.

(3)      Acts involving breach of the bureau's confidentiality and sensitive data requirements, including but not limited to failure to maintain the confidentiality of injured worker medical or claim information.

(4)    Acts involving misuse of information obtained from the bureau by means of electronic account access for a purpose other than facilitating treatment, including but not limited to engaging in advertising or solicitation directed to injured workers.

(5)      Acts involving advertising or solicitation directed to injured workers in violation of rule 4123-6-02.9 of the Administrative Code.

(6) Acts of intentional misrepresentation, misstatement, or omission of a relevant fact or other acts involving false, fraudulent, deceptive, or misleading information on reports, information, and/or documentation submitted by the provider, the provider's employees, or the provider's agents to the bureau, industrial commission, claimant, employer, or their representatives, MCO, QHP, or self-insuring employer in connection with a workers' compensation

claim.

(7) The reasons for immediate revocation or suspension of a provider's certification set forth in paragraph (C) of rule 4123-6-02.5 of the Administrative Code.

Effective:                                                             11/13/2015

Five Year Review (FYR) Dates:                         08/26/2015 and 08/25/2020

CERTIFIED ELECTRONICALLY

Certification

11/02/2015

Date

Promulgated Under:                           119.03

Statutory Authority:                           4121.12, 4121.121, 4121.30, 4121.31, 4121.44,

4121.441, 4123.05

Rule Amplifies:                                  4121.12, 4121.121, 4121.44, 4121.441

Prior Effective Dates:                         2/16/96, 2/14/05, 2/1/10, 1/1/13