SANCTIONS

1. SANCTIONS Agencies/Facilities

2. Sanctions • Sanctions are applicable to all violations of rules/regulations/contract requirements. • In the Provider manual we have grouped them into a grid showing: • Areas of risk, • Levels of Violation per area of risk; and • The 4 levels of sanctions that may be applied.

3. Areas of Risk • Insurance Risk • DHSR Type A or B violations • Health and Safety Risk • Compliance with Billing and Documentation Requirements

4. Areas of Risk Con’t • HIPAA and/or Confidentiality • Failure to meet Contract Requirements Including Timeliness of Reporting • Performance Failures in Multiple Areas

5. Levels of Violations • All areas of risk have at least three levels of severity relating to violation. Compliance billing and documentation has 4 levels. • Each level of violation has a matching level of sanction which also increases in severity.

6. Sanctions con’t • Examples of levels of possible sanctions include but are not limited to: • Level I referrals are frozen, POC required, not able to add any new services • Level II any of the above or additional audits/monitoring reviews, decrease in performance profile level may occur.

7. Sanctions con’t • Level III: any of the above mentioned plus: • Contract termination, • Decrease in level on performance profile; time lines on level I sanctions such as no new referrals are extended beyond initial sanction • Justified cause audits through plan of correction

8. Sanctions con’t • QM monitoring review must show POC has been implemented for at least 6 months before returned to regular network status • Level IV: • Compliance: Billing and Documentation if contract is not terminated reporting to state agencies may occur for suspected fraud and abuse

9. Sanctions con’t • Regulatory Compliance Committee in conjunction with Finance and Reimbursement has to approve any request for payment plans • Mandatory reduction in level of Performance Profile • This summary is not all inclusive but is to alert you of potential actions by Sandhills Center

10. Performance Failures in Multiple Areas • Network Status Warning Level: 2 or fewer Level II violations or provider has been required to develop and implement 2 POC’s with a rolling 12 month period. The provider will receive a formal warning that the 3rd violation or POC could result in termination in the Sandhills Network

11. Performance Failures in Multiple Areas con’t • Provisional Status 3 level II violations within a 12 month period (rolling months) OR 2 Level III violations • Sanction: Referrals are frozen for up to 3 months following implementation of all 3 POC’s, May not add additional services for 12 months following implementation of all 3 POC and Mandatory drop in profile status

12. Failures in Multiple Areas Con’t • Contract Termination • Provider has received more than 3 Level II violations within a 12 month period or 3 or more Level III violations or 3 violations that are a combination of Level II &III violations • OR • There is a single sentinel event that present ongoing risk to members or liability to SHC

13. Failures in Multiple Areas Con’t • Contract may be terminated • If not terminated Regulatory Compliance Committee will determine safeguards needed to allow the provider to continue to provide services, including POC’s, monitoring schedules and appropriate sanctions

14. Sanctions • This is a new way of doing business for Sandhills Center so Please take the time to carefully review the detailed information relating to sanctions provided in your packet. • If you have questions you may contact the Providerhelpdesk@sandhillscenter.org for assistance • Thank you

15. External Sanctions • These are sanctions that come from DHSR or DMA or other Licensure Boards • Areas of Risk: • Loss of Agency License • Loss of Practitioner License • Fraud and Abuse substantiated by DMA for Agencies and Practitioners and for Licensed Practitioners independently enrolled

16. External Sanctions Con’t • Violations include but are not limited to: • Licenses have been revoked or lapsed at which time referrals are immediately frozen and if children are involved they are moved to another provider/facility • Violations relating to false claims reporting

17. External Sanctions Con’t • Services will end at sanctioned site • Contract may be terminated • Paybacks may occur • Referrals to higher authorities will be made if indicated

18. Alteration of Practitioner Status • Somewhat addressed on previous slides but in summary: the following conditions can affect a Practitioner’s credentialing status • 1-Failure to maintain compliance with credentialing criteria • 2-Failure to execute contract , involved in experimental or unapproved modalities of treatment

19. Alteration of Practitioner Status • 3- Breached any material term of his/her contract including failure to comply with Medical Management or Quality Improvement requirements • 4- Sexual Contact or contact of an amorous nature with a patient, or violation of other clinician/patient boundaries

20. Alteration of Practitioner Status • Sanctions can include but are not limited to: • Plan of Correction • Site Visit • Membership Freeze for specified timeframe • Censure Letter • Payback

21. Alteration of Practitioner Status • Terminations may occur for - Breach of Contract - Refusal to comply with Sanctions - Failure to maintain license - Health and safety - Potential fraud and abuse