Gradation of Offences Sample Clauses

Gradation of Offences. On the basis of the investigation report/field audits, the following charges may be found to be reasonably proved and a gradation of penalties may be levied by the SEC. However, this tabulation is intended to be as guidelines rather than mandatory rules and the SEC may take a final call on the severity and quantum of punishment on a case to case basis. Penalties for Offences by the Hospital Case Issue First Offence Second Offence Third Offence Illegal cash payments by beneficiary Full Refund and compensation 3 times of illegal payment to the beneficiary In addition to actions as mentioned for first offence, Rejection of claim for the case De-empanelment/ black-listing Billing for services not provided Rejection of claim and penalty of 3 times the amount claimed for services not provided, to Insurance Company /State Health Agency Rejection of claim and penalty of 8 times the amount claimed for services not provided, to Insurance Company /State Health Agency De-empanelment Up coding/ Unbundling/ Unnecessary Procedures Rejection of claim and penalty of 8 times the excess amount claimed due to up coding /unbundling/Unnecessary Procedures, to Insurance Company /State Health Agency. For unnecessary procedure: Rejection of claim and penalty of 16 times the excess amount claimed due to up coding/unbundling/Unnecessary Procedures, to Insurance Company /State Health Agency De-empanelment Wrongful beneficiary Identification Rejection of claim and penalty of 3 times the amount claimed for wrongful beneficiary identification to Insurance Company /State Health Agency Rejection of claim and penalty of 8 times the amount claimed for wrongful beneficiary identification to Insurance Company /State Health Agency De-empanelment Non-adherence to AB PM-XXX quality and service standard In case of minor gaps, warning period of 2 weeks for rectification, for major gaps, Suspension of services until rectification of gaps and validation by SEC/ DEC Suspension until rectification of gaps and validation by SEC/ DEC De-empanelment
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Related to Gradation of Offences

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