§437.4. Claims review and administrative sanctions
A.(1) Pursuant to rules and regulations promulgated in accordance with the
Administrative Procedure Act, the secretary shall establish a process to review a claim made
by a health care provider to determine if the claim should be or should have been paid as
required by federal or state law or by rule.
(2) Claims review may occur prior to or after payment is made to a health care
provider.
(3) The secretary may withhold payment to a health care provider during claims
review if necessary to protect the fiscal integrity of the medical assistance programs.
(4) The administrative rules promulgated by the department to implement the claim
review process established pursuant to this Subsection shall provide for procedures to ensure
that providers receive or retain the appropriate reimbursement amount for claims in which
the department determines that services delivered have been improperly billed but were
reasonable and necessary.
B. The secretary may establish various types of administrative sanctions pursuant to
rules and regulations promulgated in accordance with the Administrative Procedure Act
which may be imposed on a health care provider or other person who violates any provision
of this Part or any other applicable federal or state law or rule related to the medical
assistance programs.
C.(1) The department shall conduct a hearing in compliance with the Administrative
Procedure Act at the request of a person who wishes to contest an administrative sanction
imposed on him by the secretary.
(2) A party aggrieved of an order may seek judicial review only in the Nineteenth
Judicial District Court for the parish of East Baton Rouge.
(3) Judicial review of the order shall be conducted in compliance with the
Administrative Procedure Act.
D. All state rules and regulations issued on or before August 15, 1997, shall be
deemed to have been issued in compliance with and under the authority of this Section.
Acts 1997, No. 1373, §1; Acts 2016, No. 467, §1.