Section 2090.100  Sanctions for Non-Compliance/Audits

a)         Failure to comply with the requirements of this Part shall result in the provider being issued a written warning or having its certification suspended or terminated for the Illinois Medical Assistance Program.

b)         The Department shall issue written notification to a certified provider who has failed to comply with any provision specified in this Part.  The provider shall have a maximum of 60 calendar days from the date of the written notice to correct the cited deficiencies.  However, such action shall not preclude the Department from initiating proceedings as specified in subsection (g) of this Section.

c)         The Department may also conduct post-payment audits based on volume of billings, complaints, identified deficiencies or non-compliance with this Part, or pursuant to a random selection process as necessary to monitor for compliance with this Part.

d)         The Department shall audit a statistically significant randomly selected sampling of client records at the audited program.

e)         The Department shall follow the recoupment formula approved by the Department of Public Aid, should the audit result in recoupment.

f)         Upon completion of the post-payment audit the Department shall submit written notification to the program regarding audit findings and amounts determined to be recoupable.  The program shall respond to the notification within 15 days with supporting documentation regarding the recoupment amount. If such documentation proves that the recoupment amount is inaccurate, the amount shall be revised.  The program may also request a 100% audit.  The department may reduce future payments at a percentage per month or in a lump sum, or demand repayment in a lump sum.

g)         The Department and the Department of Public Aid shall jointly initiate administrative proceedings pursuant to 89 Ill. Adm. Code 140.16 to suspend or terminate certification and eligibility to participate in the Illinois Medical Assistance Program for reasons set forth in 89 Ill. Adm. Code 140.16 or for failing to comply with any provision of this Part.  The Department may also initiate administrative proceedings pursuant to 89 Ill. Adm. Code 140.15 to recover money. Both types of proceedings shall be conducted under 89 Ill. Adm. Code 104: Subpart C (Rules of Practice for Medical Vendor Hearings).

(Source:  Amended at 23 Ill. Reg. 13879, effective November 4, 1999)