DHS 106.04(5)(a)(a) Except as provided in par. (b), if a provider receives a payment under the MA program to which the provider is not entitled or in an amount greater than that to which the provider is entitled, the provider shall return to the department the amount of the overpayment, including but not limited to erroneous, excess, duplicative and improper payments, regardless of cause, within 30 days after the date of the overpayment in the case of a duplicative payment from MA, medicare or other health care payer and within 30 days after the date of discovery in the case of all other overpayments.

DHS 106.04(5)(b)(b) In lieu of returning the overpayment, a provider may notify the department in writing within 30 days after the date of the overpayment or its discovery, as applicable, of the nature, source and amount of the overpayment and request that the overpayment be deducted from future amounts owed the provider by the MA program.

DHS 106.04(5)(c)(c) The department shall honor the request under par. (b) if the provider is actively participating in the program, is not currently under investigation for fraud or MA program abuse, is not subject to an intermediate sanction under s. DHS 106.08, and is claiming and receiving MA reimbursement in amounts sufficient to reasonably ensure full recovery of the overpayment within a limited period of time. Any limited recovery period shall be consistent with the applicable federally required time period for the department’s repayment of the federal financial participation associated with the overpayment as stated in 42 CFR 433.300-322.

DHS 106.04(5)(d)(d) If the department denies the provider’s request under par. (b) to have the overpayment deducted from future amounts paid, the provider shall return to the department the full amount of the overpayment within 30 days after receipt of the department’s written denial.

DHS 106.04(6)(6) Good faith payment. A claim denied for recipient eligibility reasons may qualify for a good faith payment if the service provided was provided in good faith to a recipient with an MA identification card which the provider saw on the date of service and which was apparently valid for the date of service.

DHS 106.04 HistoryHistory: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; r. (2) (b) 10. and 11., cr. (7) (f), Register, February, 1988, No. 386, eff. 3-1-88; renum. (2) (b) 5. to 9. to be 6. to 10. and am. 9. and 10., cr. (2) (b) 5., 11. and 12., Register, December, 1988, No. 396, eff. 1-1-89; emerg. am. (2) (a), r. (2) (b) to (e), renum. (2) (f) to be (2) (b), eff. 1-1-90; am. (2) (a), r. (2) (b) to (e), renum. (2) (f) to be (2) (b), Register, September, 1990, No. 417, eff. 10-1-90; emerg. cr. (1m), eff. 11-1-90; cr. (1m), Register, May, 1991, No. 425, eff. 6-1-91; am. (3) (intro.), Register, September, 1991, No. 429, eff. 10-1-91; emerg. am. (1m) (c) 1., renum. (1m) (d), (5) and (9) to be (1m) (e), (4) and (6) and am. (4), cr. (1m) (d), r. (4), (7) and (8), r. and recr. (6), eff. 7-1-92; am. (1m) (c) 1., renum. (1m) (d) and (9) to be (1m) (e) and (6), cr. (1m) (d), r. and recr. (5), r. (6) to (8), Register, February, 1993, No. 446, eff. 3-1-93; correction in (3) (b) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520; corrections in (2) (a) and (3) (c) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 106.05(1)(a)(a) Termination notice. Any provider other than a skilled nursing facility or intermediate care facility may at any time terminate participation in the program. A provider electing to terminate program participation shall at least 30 days before the termination date notify the department in writing of that decision and of the effective date of termination from the program.

DHS 106.05(1)(b)(b) Reimbursement. A provider may not claim reimbursement for services provided recipients on or after the effective date specified in the termination notice. If the provider’s notice of termination fails to specify an effective date, the provider’s certification to provide and claim reimbursement for services under the program shall be terminated on the date on which notice of termination is received by the department.

DHS 106.05(2)(a)(a) Termination notice. A provider certified under ch. DHS 105 as a skilled nursing facility or intermediate care facility may terminate participation in the program upon advance written notice to the department and to the facility’s resident recipients or their legal guardians in accordance with s. 50.03 (14) (e), Stats. The notice shall specify the effective date of the facility’s termination of program participation.

DHS 106.05(2)(b)(b) Reimbursement. A skilled nursing facility or intermediate care facility electing to terminate program participation may claim and receive reimbursement for services for a period of not more than 30 days beginning on the effective termination date. Services furnished during the 30-day period shall be reimbursable provided that:

DHS 106.05(3)(3) Record retention. Voluntary termination of a provider’s program participation under this section does not end the provider’s responsibility to retain and provide access to records as required under s. DHS 106.02 (9) unless an alternative arrangement for retention, maintenance and access has been established by the provider and approved in writing by the department.

DHS 106.05 HistoryHistory: Cr. Register, December, 1979, No. 288, eff. 2-1-80; am. Register, February, 1986, No. 362, eff. 3-1-86; correction in (2) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 106.06DHS 106.06 Involuntary termination or suspension from program participation. The department may suspend or terminate the certification of any person, partnership, corporation, association, agency, institution or other entity participating as a health care provider under the program, if the suspension or termination will not deny recipients access to MA services and if after reasonable notice and opportunity for a hearing the department finds that any of the following occurred:

DHS 106.06(1)(1) Non-compliance with MA requirements. The provider has repeatedly and knowingly failed or refused to comply with federal or state statutes, rules or regulations applicable to the delivery of, or billing for, services under the program;

DHS 106.06(3)(b)(b) Findings precipitating action by the department under this subsection shall be based on the written findings of a peer review committee established by the department or a PRO under contract to the department to review and evaluate health care services provided under the program. The findings shall be presumptive evidence that the provider has engaged in improper activities under this subsection.