DHS 106.06(4)(4) Suspension or revocation. The licensure, certification, authorization or other official entitlement required as a prerequisite to the provider’s certification to participate in the program has been suspended, restricted, terminated, expired or revoked;

DHS 106.06(4m)(4m) In the case of a freestanding personal care agency as defined in s. DHS 105.17 (1) (a), the freestanding personal care agency has violated one or more of the applicable requirements of ch. DHS 105 in a manner or to a degree that may endanger or threaten the health or safety of clients, has not paid the fee, or has failed to provide information requested by the department in connection with certification;

DHS 106.06(5)(5) Public health in jeopardy. A provider’s licensure, certification, authorization or other official entitlement has been suspended, terminated, expired or revoked under state or federal law following a determination that the health, safety or welfare of the public is in jeopardy;

DHS 106.06(6)(6) Medicare sanctions.

DHS 106.06(6)(a)(a) The provider is excluded or terminated from the medicare program or otherwise sanctioned by the medicare program because of fraud or abuse of the medicare program under 42 CFR 420.101 or 474.10.

DHS 106.06(6)(c)(c) The provider is a party convicted of a crime, ineligible to participate in the medicare program and the health care financing administration directs the department to suspend the provider;

DHS 106.06(7)(7) Service during period of noncertification. The provider has provided a service to a recipient during a period in which provider’s licensure, certification, authorization, or other entitlement to provide the service was terminated, suspended, expired or revoked;

DHS 106.06(8)(8) Criminal conviction. The provider has been convicted of a criminal offense related to providing or claiming reimbursement for services under medicare or under this or any other state’s MA program. In this subsection, “convicted” means that a judgment of conviction has been entered by a federal, state or local court, irrespective of whether an appeal from that judgment is pending;

DHS 106.06(9)(9) False statements. The provider knowingly made or caused to be made a false statement or misrepresentation of material fact in connection with provider’s application for certification or recertification;

DHS 106.06(10)(10) Failure to report status change. The provider has concealed, failed or refused to disclose any material change in licensure, certification, authorization, or ownership which, if known to the department, would have precluded the provider from being certified;

DHS 106.06(11)(11) Concealment of outside controlling interests. The provider at the time of application for certification under ch. DHS 105 or after receiving that certification knowingly misrepresented, concealed or failed to disclose to the department full and complete information as to the identity of each person holding an ownership or controlling interest in the provider;

DHS 106.06(12)(12) Concealment of provider’s controlling interests. The provider at the time of application for certification under ch. DHS 105 or after receiving that certification knowingly misrepresented, concealed or failed to disclose to the department an ownership or controlling interest the provider held in a corporation, partnership, sole proprietorship or other entity certified under the program;

DHS 106.06(13)(13) False statements concerning the nature and scope of services. The provider made or caused to be made false statements or misrepresentation of material facts in records required under s. DHS 105.02 (4), (6) or (7) and maintained by the provider for purposes of identifying the nature and scope of services provided under the program;

DHS 106.06(14)(14) False statements concerning the costs of services. The provider has knowingly made or caused to be made false statements or has misrepresented material facts in connection with the provider’s usual and customary charges submitted to the department as a claim for reimbursement;

DHS 106.06(15)(15) False statements concerning cost reports. The provider has knowingly made or caused to be made false statements or misrepresentation of material facts in cost reports relating to the provider’s costs, expenditures or usual and customary charges submitted to the department for the purpose of establishing reimbursement rates under the program;

DHS 106.06(16)(16) Failure to keep records. The provider has failed or refused to prepare, maintain or make available for inspection, audit or copy by persons authorized by the department, records necessary to fully disclose the nature, scope and need of services provided recipients;

DHS 106.06(17)(17) False statement on claim. The provider has knowingly made or caused to be made a false statement or misrepresentation of a material fact in a claim;

DHS 106.06(18)(18) Obstruction of investigation. The provider has intentionally by act of omission or commission obstructed an investigation or audit being conducted by authorized departmental personnel pursuant to s. 49.45 (3) (g), Stats.;

DHS 106.06(19)(19) Payment for referral. The provider has offered or paid to another person, or solicited or received from another person, any remuneration in cash or in kind in consideration for a referral of a recipient for the purpose of procuring the opportunity to provide covered services to the recipient, payment for which may be made in whole or in part under the program;

DHS 106.06(20)(20) Failure to request copayments. The provider has failed to request from recipients the required copayment, deductible or coinsurance amount applicable to the service provided to recipients after having received a written statement from the department noting the provider’s repeated failure to request required copayments, deductible or coinsurance amounts and indicating the intent to impose a sanction if the provider continues to fail to make these requests;

DHS 106.06(21)(21) Charging recipient. The provider has, in addition to claiming reimbursement for services provided a recipient, imposed a charge on the recipient for the services or has attempted to obtain payment from the recipient in lieu of claiming reimbursement through the program contrary to provisions of s. DHS 106.04 (3);

DHS 106.06(22)(22) Racial or ethnic discrimination. The provider has refused to provide or has denied services to recipients on the basis of the recipient’s race, color or national origin in violation of the Civil Rights Act of 1964, as amended, 42 USC 200d, et. Seq., and the implementing regulations. 45 CFR Part 80.

DHS 106.06(23)(23) Disability discrimination. The provider has refused to provide or has denied services to a recipient with a disability solely on the basis of disability, thereby violating section 504 of the Rehabilitation Act of 1973, as amended, 29 USC 794.

DHS 106.06(24)(24) Funds mismanagement. A provider providing skilled nursing or intermediate care services has failed to or has refused to establish and maintain an accounting system which ensures full and complete accounting of the personal funds of residents who are recipients, or has engaged in, caused, or condoned serious mismanagement or misappropriation of the funds;

DHS 106.06(25)(25) Refusal to repay erroneous payments. The provider has failed to repay or has refused to repay amounts that have been determined to be owed the department either under s. DHS 106.04 (5) or pursuant to a judgment of a court of competent jurisdiction, as a result of erroneous or improper payments made to the provider under the program;

DHS 106.06(26)(26) Faulty submission of claims, failure to heed MA billing standards, or submission of inaccurate billing information. The provider has created substantial extraordinary processing costs by submitting MA claims for services that the provider knows, or should have known, are not reimbursable by MA, MA claims which fail to provide correct or complete information necessary for timely and accurate claims processing and payment in accordance with proper billing instructions published by the department or the fiscal agent, or MA claims which include procedure codes or procedure descriptions that are inconsistent with the nature, level or amount of health care provided to the recipient, and, in addition, the provider has failed to reimburse the department for extraordinary processing costs attributable to these practices;