View
35
Download
2
Category
Preview:
DESCRIPTION
Child & Adult Care Food Program Serious Deficiency Process & Provider Appeals. Overview. Federal law (ARPA) mandated changes for providers Established serious deficiency process for providers Suspension for health or safety violations Provider appeals. - PowerPoint PPT Presentation
Citation preview
Child & Adult Care Child & Adult Care Food ProgramFood Program
Serious Deficiency Serious Deficiency ProcessProcess& Provider Appeals& Provider Appeals
2
OverviewOverviewFederal law (ARPA) mandated changes for providers
Established serious deficiency process for providers
Suspension for health or safety violations
Provider appeals
3
Why do we need provider Why do we need provider appeal rights?appeal rights?• Problem of non-compliant providers
switching sponsors• Federal law requires USDA to
maintain a National Disqualified List of terminated providers
• Importance of protecting provider rights
4
Termination for cause or for Termination for cause or for convenienceconvenience
• Violation of agreement = termination for cause
Initiated by the Sponsor
• Termination for convenience = non-performance issues
Initiated by the provider or the Sponsor
5
A rose by any other nameA rose by any other name
• Fair hearing = administrative review = appeal
• Administrative review official = hearing official = hearing officer = appeal officer
6
What can be appealed?What can be appealed?• Proposed termination for cause and
proposed disqualification
• Suspension for health or safety violations
7
What cannot be appealed?What cannot be appealed?
Anything else
8
WhenWhen is an action is an action appealable?appealable?
• Sponsor issues a Notice of Proposed Termination for Cause and Proposed Disqualification
• Sponsor issues a Suspension Notice
A provider may request an appeal when:
9
How will providers know How will providers know about their appeal rights?about their appeal rights?• Language in the agreement between
the sponsor and the provider• Sponsor gives a copy of the appeal
procedures to the provider– Annually– When any appealable action is taken– Upon request
10
Minimum appeal Minimum appeal proceduresprocedures• Uniformity
• Representation
• Review of record and opposition
• In-person hearing not required
11
Minimum appeal Minimum appeal procedures (cont.)procedures (cont.)
• Basis for decision
• Timeframes for issuing a decision
• Final administrative decision
12
Supplemental proceduresSupplemental procedures
• Must be consistent with minimum procedures
• Examples– Timeframe for appeal decision– Deadline for requesting an appeal– Deadline for submitting additional
written documentation
13
Supplemental proceduresSupplemental procedures(cont.)(cont.)
• More examples – In-person hearing
– Additional appealable actions
• State agency approval required
14
Ensuring complianceEnsuring compliance• State agency must ensure sponsors
properly implement provider appeal process
– Part of state agency review of sponsors
– Improper implementation of a provider appeal process = Seriously Deficient
15
Serious deficienciesSerious deficiencies
• Submission of false information
• Submission of false claims
• Simultaneous participation under more than 1 sponsor
• Meal pattern non-compliance
16
Serious deficienciesSerious deficiencies• Failure to keep required records
• Imminent threat to health or safety
• Conviction indicating lack of business integrity during the past 7 years
• Any other circumstance related to non-performance under agreement
17
Convictions indicating a Convictions indicating a lack of business integritylack of business integrity
• Past 7 years
• Criminal convictions only
18
Sponsor discretionSponsor discretion • Distinguish between:
– Occasional errors and systemic errors
– Minor errors and major errors
• Improper use of termination for convenience = serious deficiency
19
Error or serious deficiencyError or serious deficiencyFactors to consider:
– Frequency of the error– Severity of the error– Length of program experience– Literacy level or English proficiency
Provider must move to full compliance ASAP
20
Serious Deficiency Serious Deficiency Process for ProvidersProcess for Providers
21
Steps in the processSteps in the process• Serious deficiency determination
• Serious deficiency notice
• Opportunity for corrective action
• Proposed termination/disqualification
• Appeal
22
Seriously Deficient noticeSeriously Deficient notice Notice must be in writing and contain
certain information: Fully describe the serious deficiency Specify the corrective action required
to resolve the serious deficiency & deadline
State that serious deficiency determination is not subject to appeal
23
Seriously Deficient noticeSeriously Deficient notice Must state that failure to fully and
permanently correct the serious deficiency by the deadline will result in:
• proposed termination of the provider’s agreement for cause, and
• proposed disqualification of the provider.
24
Seriously Deficient noticeSeriously Deficient notice • Must inform provider if she/he will
receive CACFP payments during the period of corrective action
• Must state that if the provider voluntarily terminates her/his agreement after receiving the notice, the sponsor will still proceed with the proposed disqualification.
25
Seriously Deficient noticeSeriously Deficient notice Sponsor must
continue to pay valid claims
26
Timeframes for corrective Timeframes for corrective actionaction
• Deficiency must be corrected within 30 days
• Ensure prompt resolution
• No provision that allows sponsors to give providers additional time
27
Opportunity for corrective Opportunity for corrective actionaction
Yes, but …
No corrective action allowed before suspension for imminent threat to health or safety
28
False or Fraudulent False or Fraudulent ClaimsClaims • No provision to suspend provider
participation
• Opportunity to correct
29
False or Fraudulent False or Fraudulent Claims (con’t)Claims (con’t)
• Declare the provider seriously deficient
• Opportunity for corrective action
30
False or Fraudulent False or Fraudulent Claims (con’t)Claims (con’t) Deny the claim/recover payment
– Never reimburse providers for invalid claims
– Do not reimburse for invalid portion of claim
31
An Example of False or An Example of False or Fraudulent ClaimsFraudulent Claims
• Four enrollment forms, three children in care.
• Claiming 5-7 children for 3 months
• No explanation
• Provider is declared Seriously Deficient
• While corrective action and appeal occur, the invalid portion of the provider’s claims must not be paid.
32
Verifying Corrective Verifying Corrective ActionAction• Unannounced
follow-up review recommended
• Refer to Nebraska Management Standards: Provider Serious Deficiencies & Corresponding Corrective Action Plan
33
What Happens Next?What Happens Next?• If serious deficiency is corrected
– Notify provider & state agency
• If serious deficiency is not corrected– Notice of Proposed
Termination/placement on National Disqualified List is sent to provider & state agency
34
Notice of Notice of Proposed Proposed Termination/DisqualificationTermination/Disqualification
• Propose to terminate agreement for cause
• Propose to disqualify provider• Basis for actions = inadequate
corrective action
35
Notice of Notice of Proposed Proposed Termination/DisqualificationTermination/Disqualification• Procedures for appeal • Status of program payments• Voluntary termination =
disqualification
36
Status of Program PaymentsStatus of Program Payments• General rule: Program participation,
including Program payments, continues during the serious deficient process
• One exception– Suspended providers
• Sponsors must always deny invalid claims
37
Provider decides to Provider decides to appealappeal• Provider must submit request for
administrative review/hearing within time frame specified by sponsor
• Provider & sponsor submit documentation to hearing official
• Hearing official reviews the record or sets date for in-person hearing
38
The hearing officialThe hearing official
• Hearing official must be:– Independent– Impartial
• Hearing official may be:– An employee or board member of the
sponsor– A contractor (e.g. sponsor
association)
39
Role of the hearing officialRole of the hearing official• Review the evidence, documentation
and testimony
• Remain objective
• Determine if the sponsor complied with regulatory procedures
• Issue a decision based on the facts, not opinion or feelings
40
Review of record or Review of record or hearinghearing
• Review all evidence and testimony• Issue decision in writing
– Decision sent to provider and sponsor at same time
41
No place to set policyNo place to set policy• The hearing official is being
asked:Has the program requirement been
properly applied?
NOT
Do you agree with the requirement?
42
In-person hearingsIn-person hearings• Allow both sides to present
their case, introduce evidence, call witnesses
• Keep proceedings on track• Maintain decorum
43
In-person hearingsIn-person hearings• Remain objective• Tape record proceedings, if
desired• Don’t issue your decision at
the hearing
44
Resources for hearing Resources for hearing officersofficers• Federal
Regulations 7 CFR 226
• Copy of sponsor/provider agreement
• Copy of sponsor’s appeal procedures
45
Resources for hearing Resources for hearing officersofficers
• Copy of sponsor’s manual or handbook for providers
• Copies of sponsor’s administrative memos or other communication to providers
46
Termination of the Termination of the AgreementAgreement
• Provider fails to appeal
• Hearing official rules in favor of sponsor
47
Removal fromRemoval fromthe National Disqualified the National Disqualified ListList
• Generally removed after 7 years
• Two exceptions:– If SD is permanently corrected,
removal before 7 years– If provider still owes a debt after 7
years, will remain on list until repaid
48
Applying after Applying after DisqualificationDisqualification
• What if a provider is on National Disqualified List?
• Sponsor is not required to:– Offer provider an appeal– Assist provider with removal from
National Disqualified List
49
How Long?How Long?
• Provider is placed on the National Disqualified List or on a state agency list prior to July 29, 2002, will remain for 7 years
• Must remain on the list until July 29, 2009; longer if a debt is still owed
50
AAQQ&&
51
Question?Question? What if the provider wins the appeal?
52
AnswerAnswer• Notify provider/state agency• Remove the seriously deficient
determination
53
Wouldn’t it be simpler to allow the home to terminate for convenience after serious deficiency is declared?
Question?Question?
54
AnswerAnswerEasier, but the provider could participate with another sponsor
55
Who is the action taken against when the provider is incorporated—the provider or the corporation?
Question?Question?
56
AnswerAnswerBoth
57
Can a sponsor permit more than 30 days for corrective action?
Question?Question?
58
AnswerAnswer
NO
59
QuestionsQuestions• Will homes be notified they are off the
National Disqualified List after 7 years? – No. This is not required.
60
And justice for all . . .And justice for all . . .
Thank you for your contributions to maintaining integrity in the Child and Adult Care Food Program.
Recommended