(a) The department shall not enroll any applicant that has been convicted of any felony or misdemeanor involving fraud or abuse in any government program, or related to neglect or abuse of a patient in connection with the delivery of a health care item or service, or in connection with the interference with or obstruction of any investigation into health care related fraud or abuse or that has been found liable for fraud or abuse in any civil proceeding, or that has entered into a settlement in lieu of conviction for fraud or abuse in any government program, within the previous 10 years. In addition, the department may deny enrollment to any applicant that, at the time of application, is under investigation by the department or any state, local, or federal government law enforcement agency for fraud or abuse pursuant to Subpart A (commencing with Section 455.12) of Part 455 of Title 42 of the Code of Federal Regulations. The department shall not deny enrollment to an otherwise qualified applicant whose felony or misdemeanor charges did not result in a conviction solely on the basis of the prior charges. If it is discovered that a provider is under investigation by the department or any state, local, or federal government law enforcement agency for fraud or abuse, that provider shall be subject to temporary suspension from the Medi-Cal program, which shall include temporary deactivation of the provider’s number, including all business addresses used by the provider to obtain reimbursement from the Medi-Cal program.

(b) If it is discovered that a provider has been terminated under Medicare or under the Medicaid program or Children’s Health Insurance Program in any other state, the provider shall not be enrolled in, or shall be subject to termination from, the Medi-Cal program, which shall include deactivation of the provider’s enrolled numbers and all business addresses used to obtain reimbursement from the Medi-Cal program.

Terms Used In California Welfare and Institutions Code 14043.36

  • Abuse: means either of the following:

    California Welfare and Institutions Code 14043.1

  • Applicant: means an individual, including an ordering, referring, or prescribing individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents thereof, that apply to the department for enrollment as a provider in the Medi-Cal program. See California Welfare and Institutions Code 14043.1
  • Convicted: means any of the following:

    California Welfare and Institutions Code 14043.1

  • Conviction: A judgement of guilt against a criminal defendant.
  • department: means the State Department of Health Services. See California Welfare and Institutions Code 14062
  • director: means the State Director of Health Services. See California Welfare and Institutions Code 14061
  • Fraud: Intentional deception resulting in injury to another.
  • Fraud: means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person. See California Welfare and Institutions Code 14043.1
  • Medi-Cal: means the California Medical Assistance Program. See California Welfare and Institutions Code 14063
  • Provider: means an individual, partnership, group, association, corporation, institution, or entity, and the officers, directors, owners, managing employees, or agents of a partnership, group association, corporation, institution, or entity, that provides services, goods, supplies, or merchandise, directly or indirectly, including all ordering, referring, and prescribing, to a Medi-Cal beneficiary and that has been enrolled in the Medi-Cal program. See California Welfare and Institutions Code 14043.1
  • Resolution of an investigation for fraud or abuse: means there is no documentation to indicate either that a charge or accusation has been filed against the provider and either (1) the investigation has not been active at any time during the previous 12 months or (2) the department has made a documented good faith effort and has been unable, for a period of 12 months, to contact an investigator or responsible representative of any agency investigating the provider. See California Welfare and Institutions Code 14043.1
  • Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.

(c) The director shall notify in writing the provider of the temporary suspension and deactivation of the provider’s number, which shall take effect 15 days from the date of the notification. Notwithstanding § 100171 of the Health and Safety Code, proceedings after the imposition of sanctions provided for in subdivision (a) shall be in accordance with Section 14043.65.

(d) A temporary suspension may be lifted when a resolution of an investigation for fraud or abuse occurs.

(Amended by Stats. 2015, Ch. 271, Sec. 5. (SB 299) Effective September 4, 2015.)

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