Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 2336 (April 27, 2024).

55 Pa. Code § 1101.73. Provider misutilization and abuse.

§ 1101.73. Provider misutilization and abuse.

 If the Department’s routine utilization review procedures indicate that a provider has been billing for services that are inconsistent with MA regulations, unnecessary, inappropriate to patients’ health needs or contrary to customary standards of practice, the provider will be notified in writing that payment on all of his invoices will be delayed or suspended for a period not to exceed 120 days pending a review of his billing and service patterns. Some providers may have their invoices reviewed prior to payment. In addition, the provider’s medical or fiscal records, or both, may be reviewed and he may be asked to appear before one of the Department’s peer review committees to explain his billing practices. Written notice of the Department’s action to delay payment will also be sent to the PSRO, where applicable.

Cross References

   This section cited in 55 Pa. Code Chapter 1181 Appendix O (relating to OBRA sanctions); and 55 Pa. Code §  5221.43 (relating to quality assurance and utilization review).

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