Section 22.82. False or fraudulent claims by providers

An enrolled provider submits a false or fraudulent claim if the provider directly or indirectly commits one or more of the following acts:

(1) Submits false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled for dispensing prescription drugs under PACE.

(2) Submits a claim for dispensing only part of a prescription amount which is less than the maximum limit of the program except when the provider can document that insufficient inventory prevented the dispensing of the program limit and that no additional dispensing fee or copayments were charged for dispensing the remainder of the prescription at a later time.

(3) Submits false information to obtain authorization to dispense prescription drugs under PACE.

(4) Solicits, receives, offers or pays remuneration, including a kickback, bribe or rebate, directly or indirectly in cash or in kind, from or to a person in connection with the dispensing of prescription drugs or referral of claimants for prescription drugs.

(5) Submits a duplicate claim for prescription drugs for which the provider has already received or claimed reimbursement from any source.

(6) Submits a claim for prescription drugs which were not dispensed by the provider at the provider’s principal place of business or were not dispensed to a claimant.

(7) Submits a claim for prescription drugs dispensed which are not documented in the prescribed manner. See 49 Pa. Code Chapters 16—18 (relating to State Board of Medicine—general provisions; State Board of Medicine—medical doctors; and State Board of Medicine—practitioners other than doctors) and 49 Pa. Code § 27.78 (relating to standards of practice).

(8) Submits a claim, order or prescription, for prescription drugs which are of little or no benefit to the claimant, are below accepted treatment standards or are not medically necessary, in the case of a dispensing physician who is a provider.

(9) Submits a claim which misrepresents the description of the prescription drugs dispensed, the date of service, the identity of the claimant, the identity of the prescriber or the identity of the actual provider.

(10) Submits a claim for a prescription drug dispensed under PACE at a cost that is greater than the provider’s usual charge to the general public.

(11) Submits a claim for a prescription drug dispensed for which the provider has not collected from the claimant all due payments, including the required copayment and any applicable generic differential.

(12) Enters into an agreement, combination or conspiracy to obtain or aid another in obtaining from the Department payment to which the provider or other person is not entitled.

(13) Submits a claim for prescription drugs dispensed to a claimant outside this Commonwealth.

The provisions of this § 22.82 adopted December 15, 1984, effective December 16, 1984, 14 Pa.B. 2109; amended December 14, 1990, effective December 15, 1990, 20 Pa.B. 6143. Immediately preceding text appears at serial pages (115964) and (96841).

Notation

Notes of Decisions

Violation of Agreement

Pharmacy that participated in the Pharmaceutical Assistance Contract for the Elderly program sought return of moneys Department of Aging recouped from claims it submitted to the Department; pharmacy violated its provider agreement by failing to use the correct National drug code on its claims for reimbursement, which authorized the Department to seek restitution of moneys for which it had reimbursed pharmacy. Christian St. Pharm. v. Pa. Dept. of Aging, 946 A.2d 798, 802 (Pa. Cmwlth. 2008).

Cross References

This section cited in 6 Pa. Code § 22.62 (relating to conditions of provider participation); and 6 Pa. Code § 22.84 (relating to administrative actions and penalties).