DHS 108.02(9)(d)6.e.e. Law enforcement declines to certify that a matter continues to be under investigation.
DHS 108.02(9)(d)6.f.f. The department determines that payment suspension is not in the best interests of the MA program.
DHS 108.02(9)(d)7.7. The department may find that good cause exists to suspend payments in part, or to convert a previously imposed payment suspension in whole to one only in part, to a provider against which there is an investigation of a credible allegation of fraud if any of the following are applicable:
DHS 108.02(9)(d)7.a.a. Beneficiary access to items or services would be jeopardized by a payment suspension in whole or part because provider is the sole community physician or the sole source of essential specialized services in a community, or the provider serves a large number of beneficiaries within a health resources and services administration-designated medically underserved area.
DHS 108.02(9)(d)7.b.b. The department determines, based upon the submission of written evidence by the provider, that the suspension should be imposed only in part.
DHS 108.02(9)(d)7.c.c. The credible allegation focuses solely and definitively on only a specific type of claim or arises from only a specific business unit of the provider and the department determines and documents in writing that a payment suspension in part would effectively ensure that potentially fraudulent claims were not continuing to be paid.
DHS 108.02(9)(d)7.d.d. Law enforcement declines to certify that a matter continues to be under investigation.
DHS 108.02(9)(d)7.e.e. The department determines that payment suspension is not in the best interests of the MA program.
DHS 108.02(9)(d)8.8. The department shall do all of the following relative to documentation and record retention:
DHS 108.02(9)(d)8.a.a. Maintain for a minimum of 5 years from the date of issuance all materials documenting the life cycle of a payment suspension that was imposed in whole or part, including all notices of suspension of payment in whole or part, all fraud referrals to the department of justice medicaid fraud control and elder abuse unit, all quarterly certifications of continuing investigation status by law enforcement, and all notices documenting the termination of a suspension.
DHS 108.02(9)(d)8.b.b. Maintain for a minimum of 5 years from the date of issuance all materials documenting each instance where a payment was not imposed, imposed only in part, or discontinued for good cause. This type of documentation shall include, at a minimum, detailed information on the basis for the existence of the good cause not to suspend payments, to suspend payments only in part, or to discontinue a payment suspension and, where applicable, must specify how long the department anticipates such a good cause will exist.
DHS 108.02(9)(d)8.c.c. Annually report to the Secretary of the U.S. Health and Human Services.
DHS 108.02(9)(e)(e) Request for hearing on recovery action. If a provider chooses to contest the propriety of a proposed recovery under par. (a), the provider shall, within 20 days after receipt of the department’s notice of intent to recover, request a hearing on the matter. The request shall be in writing and shall briefly identify the basis for contesting the proposed recovery. Receipt of a timely request for hearing shall prevent the department from making the proposed recovery while the hearing proceeding is pending. If a timely request for hearing is not received, the department may recover from current or future obligations of the program to the provider the amount specified in the notice of intent to recover and may take such other legal action as it deems appropriate to collect the amount specified. All hearings on recovery actions by the department shall be held in accordance with the provisions of ch. 227, Stats. The date of service of a provider’s request for a hearing shall be the date on which the department of administration division of hearings and appeals receives the request.
DHS 108.02(10)(10)Estate recovery. The department shall file a claim against the estate of a recipient or client or against the estate of the surviving spouse of a recipient or client as provided in ss. 49.496 and 49.849, Stats., and s. 46.27 (7g), 2017 Stats., to recover only the following:
DHS 108.02(10)(a)(a) The amount of medical assistance paid on or after October 1, 1991, on behalf of the recipient while the recipient resided in a nursing home.
DHS 108.02(10)(b)(b) The amount of medical assistance paid on or after July 1, 1995, on behalf of the recipient while the recipient was an inpatient in a hospital and was required to contribute to the cost of care pursuant to s. DHS 103.07 (1) (d).
DHS 108.02(10)(c)(c) The amount of medical assistance paid on or after July 1, 1995, for any of the following services provided to the recipient under the medical assistance program or any federal medical assistance waiver program under 42 USC 1396n (c) or 1396u after the recipient attained 55 years of age:
DHS 108.02(10)(c)1.1. Each of the following home health services.
DHS 108.02(10)(c)1.a.a. Skilled nursing services specified in s. DHS 107.11 (2) (c) 1.
DHS 108.02(10)(c)1.b.b. Home health aide services specified in s. DHS 107.11 (2) (c) 2.
DHS 108.02(10)(c)1.c.c. Therapy and speech pathology services specified in s. DHS 107.11 (2) (c) 3.
DHS 108.02(10)(c)2.2. Private duty nursing services specified in s. DHS 107.12.
DHS 108.02(10)(c)3.3. Home and community-based waiver services provided pursuant to a waiver authorized under 42 USC 1396n (c) or 1396u.
DHS 108.02(10)(c)4.4. Inpatient covered hospital services specified in s. DHS 107.08 (1) (a) provided during a period of time in which the recipient was approved to have home and community-based waiver services funded pursuant to 42 USC 1396n (c) or 1396u.
DHS 108.02(10)(c)5.5. Inpatient services which are billed separately by providers and which are listed as non-covered hospital services in s. DHS 107.08 (4) (d) provided during a period of time in which the recipient was approved to have home and community-based waiver services funded pursuant to 42 USC 1396n (c) or 1396u.
DHS 108.02(10)(c)6.6. Legend drugs under s. DHS 107.10 provided during a period of time in which the recipient was approved to have home and community-based waiver services funded pursuant to 42 USC 1396n (c) or 1396u.
DHS 108.02(10)(d)(d) The amount of long-term community support services paid on or after January 1, 1996, on behalf of a client for services funded under s. 46.27 (7), 2017 Stats., after the client attained 55 years of age.
DHS 108.02(11)(11)Estate recovery adjustments.
DHS 108.02(11)(a)(a) The department may make adjustments to and settle estate claims and liens filed under s. 49.496 or 49.849, Stats., and s. 46.27 (7g), 2017 Stats., to obtain the fullest amount practicable.