53-6-111. Department charged with administration and supervision of medical assistance program -- overpayment recovery -- sanctions for fraudulent and abusive activities -- adoption of rules. (1) The department of public health and human services may administer and supervise a vendor payment program of medical assistance under the powers, duties, and functions provided in Title 53, chapter 2, and this chapter and that is in compliance with Title XIX of the Social Security Act.
(2) (a) The department is entitled to collect from a provider, and a provider is liable to the department for:
(i) the amount of a payment under this part to which the provider was not entitled if the incorrect payment was the result of the provider's error or if the provider's interpretation of the pertinent rule or billing code is not reasonable; and
(ii) the portion of any interim rate payment that exceeds the rate determined retrospectively by the department for the rate period.
(b) If the decision regarding the amount of a payment to which the provider was not entitled depends on an interpretation of a pertinent rule or billing code, the provider has the burden of proving that its interpretation is reasonable and consistent with:
(i) the information given to providers in any applicable Montana medicaid provider rules or manual, including but not limited to the Coding Resources identified in or incorporated by reference in any applicable Montana medicaid provider rule or manual; and
(ii) any written interpretations by the department that were in existence at the time payment was made to the provider.
(c) In addition to the amount of overpayment recoverable under subsection (2)(a), the department is entitled to interest on the amount of the overpayment at the rate specified in 31-1-106 from the date 30 days after the date of mailing of notice of the overpayment by the department to the provider, except that interest accrues from the date of the incorrect payment when the payment was obtained by fraud or abuse.
(d) The department may collect any amount described in subsection (2)(a) by:
(i) withholding current payments to offset the amount due;
(ii) applying methods and using a schedule mutually agreeable to the department and the provider; or
(iii) any other legal means.
(e) The department may suspend payments to a provider for disputed items pending resolution of a dispute.
(f) The fact that a provider may have ceased providing services or items under the medical assistance program, may no longer be in business, or may no longer operate a facility, practice, or business does not excuse repayment under this subsection (2).
(3) The department shall adopt rules establishing a system of sanctions applicable to providers who engage in fraud and abuse. Subject to the definitions in 53-6-155, the department rules must include but are not limited to specifications regarding the activities and conduct that constitute fraud and abuse.
(4) Subject to subsections (5) and (6), the sanctions imposed under rules adopted by the department under subsection (3) may include but are not limited to:
(a) required courses of education in the rules governing the medicaid program;
(b) suspension of participation in the program for a specified period of time;
(c) permanent termination of participation in the medical assistance program; and
(d) imposition of civil monetary penalties imposed under rules that specify the amount of penalties applicable to a specific activity, act, or omission involving intentional or knowing violation of specified standards.
(5) In all cases in which the department may recover medicaid payments or impose a sanction, a provider is entitled to a hearing under the provisions of Title 2, chapter 4, part 6. This section does not require that the hearing under Title 2, chapter 4, part 6, be granted prior to recovery of overpayment.
(6) The remedies provided by this section are separate and cumulative to any other administrative, civil, or criminal remedies available under state or federal law, regulation, rule, or policy.