TCA § 71-5-118 — Contracts with vendors — Sanctions against vendors — Grounds for actions against providers — Administrative remedy to recover benefits from applicant — Collection activity report — Applicant warning — Prompt process of hospital presumptive eligibility applications

The commissioner of finance and administration has the authority to enter into contracts with qualified vendors to provide to eligible recipients medical assistance allowed under § 71-5-107. The commissioner has the authority to terminate or suspend existing contracts with providers, to refuse to enter into contracts with providers, and to recover any payments incorrectly paid if the commissioner finds that such actions will further the purpose of this section. Any action against such provider shall be treated as a contested case in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5. If a hearing is requested by the provider, it shall be held prior to the imposition of any of the sanctions of this subsection (a), except that upon a finding by the commissioner that the public health, safety, or welfare imperatively requires emergency action, these sanctions may be imposed pending an opportunity for the provider to request a prompt hearing. Furthermore, the commissioner has the right to set off any money incorrectly paid against any claim for money submitted by the provider pending an opportunity for a hearing. Grounds for action against providers under this subsection (a) include, but are not limited to, the following: Violation of the terms of the contract; Violation of any provision of this part or the rules promulgated pursuant to this part; Billing for medical assistance that was not delivered; Provision of medical assistance that is not medically necessary or justified; Provision of medical assistance of a quality that is below professionally recognized standards; Revocation or suspension of a provider's professional license or other disciplinary action by the agency regulating the profession of the provider; and Failure to produce records, upon request, by authorized representatives of the commissioner as necessary to substantiate the medical assistance for which claims have been submitted. Without regard to any other civil or criminal liability that might attach, by operation of this section or any other law, to an enrollee or applicant's action in obtaining medical assistance or any assistance under this part, to which such person is not entitled, the bureau of TennCare shall have an administrative remedy for the recovery of the amount of any medical assistance benefits or payments improperly paid as a result of any misrepresentation made by such person, to the extent that such amount has not otherwise been recovered by the bureau. The bureau shall also have a right to recover in such administrative proceedings its reasonable costs and attorneys' fees, as well as interest on the amount owed by the person, calculated from the date that medical assistance was improperly paid. Any action against such person shall be treated as a contested case in accordance with the Uniform Administrative Procedures Act. In an administrative action under this subsection (b), the bureau shall show that the amount sought to be recovered was paid in the form of medical assistance as a result of material misrepresentation by the person against whom recovery is sought, but the bureau need not show that such misrepresentation was intentional or fraudulent. The bureau of TennCare shall report annually in writing to the judiciary committee of the senate, the judiciary committee of the house of representatives, and the committee of the house of representatives having oversight over TennCare regarding its collection activities of the estate recovery provisions of this chapter. All applicants for medical assistance under this part, and all applicants for reverification of eligibility to receive such assistance, shall receive a warning, in easily readable language, regarding the state recovery provisions, as well as the administrative, civil and criminal liability provisions of this chapter. The participating provider shall strive to process hospital presumptive eligibility applications within the first twenty-four (24) hours of the date of admission, when practicable. To the extent a participating provider fails to adhere to this standard, the bureau of TennCare may take remedial steps as allowed by federal law.