Senate Bill 2124
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Florida Senate - 1999 SB 2124
By Senator Saunders
25-813A-99
1 A bill to be entitled
2 An act relating to Medicaid physician fraud;
3 creating s. 409.9131, F.S.; providing
4 legislative findings and intent; providing
5 definitions; providing for review of certain
6 physician records; requiring notice before such
7 review is conducted; requiring notice of due
8 process rights in certain circumstances;
9 specifying procedures for determination of
10 overpayment; providing guidelines for sanctions
11 in cases of overbilling and acceptance of
12 overpayment; providing an effective date.
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14 Be It Enacted by the Legislature of the State of Florida:
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16 Section 1. Section 409.9131, Florida Statutes, is
17 created to read:
18 409.9131 Special provisions relating to integrity of
19 the Medicaid program.--
20 (1) LEGISLATIVE FINDINGS AND INTENT.--It is the intent
21 of the Legislature that physicians be subject to Medicaid
22 fraud and abuse investigations in accordance with the
23 provisions set forth in this section as a supplement to the
24 provisions contained in s. 409.913. If a conflict exists
25 between the provisions of this section and s. 409.913, it is
26 the intent of the Legislature that the provisions of this
27 section control.
28 (2) DEFINITIONS.--For the purposes of this section,
29 the term:
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1 (a) "Active practice" means that a physician must have
2 regularly provided medical care and treatment to patients
3 within the past 3 years.
4 (b) "Medical necessity" or "medically necessary" means
5 that the provision of goods or services is necessary to
6 palliate the effects of a terminal condition or to prevent,
7 diagnose, correct, cure, alleviate, or preclude deterioration
8 of a condition that threatens life, causes pain or suffering,
9 or results in illness or infirmity, which goods or services
10 are provided in accordance with generally accepted standards
11 of medical practice. For purposes of determining Medicaid
12 reimbursement, the agency is the final arbiter of medical
13 necessity. In making determinations of medical necessity, to
14 the maximum extent possible, the agency must use a physician
15 in active practice, either employed by or under contract with
16 the agency, of the same specialty or subspecialty and who is
17 licensed under the same chapter as the physician under review.
18 Such determination must be based upon the information
19 available at the time the goods or services were provided.
20 (c) "Peer" means a physician licensed in this state
21 who is, whenever possible, of the same specialty or
22 subspecialty and who is licensed under the same chapter as the
23 physician under review and in active practice.
24 (d) "Peer review" means an evaluation of the
25 professional practices of a Medicaid physician provider by a
26 peer or peers in order to assess the medical necessity,
27 appropriateness, and quality of care provided, as such care is
28 compared to that customarily furnished by the physician's
29 peers and to recognized health care standards.
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1 (e) "Physician" means a person licensed to practice
2 medicine under chapter 458 or a person licensed to practice
3 osteopathic medicine under chapter 459.
4 (f) "Professional services" means procedures provided
5 to a Medicaid recipient, either directly by or under the
6 supervision of a physician who is a registered provider for
7 the Medicaid program.
8 (3) ONSITE RECORDS REVIEW; APPOINTMENT REQUIRED.--As
9 specified in s. 409.913(8), the agency may investigate, review
10 or analyze a physician's medical records of Medicaid patients.
11 The physician must make such records available to the agency
12 during normal business hours. The agency must provide notice
13 to the physician at least 24 hours before such visit, and the
14 physician may schedule an appointment for the agency's visit
15 within the 24-hour period, if necessary to avoid disruption of
16 patient care.
17 (4) NOTICE OF DUE PROCESS RIGHTS REQUIRED.--Whenever
18 the agency seeks an administrative remedy against a physician
19 pursuant to this section or s. 409.913, the physician must be
20 advised of his or her rights to due process under chapter 120.
21 (5) DETERMINATIONS OF OVERPAYMENT; EDUCATIONAL AUDIT
22 REQUIRED.--In making a determination of overpayment to a
23 physician, the agency must:
24 (a) Use accepted and valid auditing, accounting,
25 analytical, statistical, or peer-review methods or
26 combinations thereof. Appropriate statistical methods may
27 include, but are not limited to, sampling and extension to the
28 population, parametric and nonparametric statistics, tests of
29 hypotheses, and other generally accepted statistical methods.
30 To the maximum extent possible, such statistical methods for
31 physician services must compare physicians of the same
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1 specialty or subspecialty, if applicable; must take into
2 consideration the physician's case mix; and must have a 95
3 percent or greater confidence level. Appropriate analytical
4 methods may include, but are not limited to, reviews to
5 determine variances between the quantities of products that a
6 provider had on hand and available to be purveyed to Medicaid
7 recipients during the review period and the quantities of the
8 same products paid for by the Medicaid program for the same
9 period, taking into appropriate consideration sales of the
10 same products to non-Medicaid customers during the same
11 period. In meeting its burden of proof in any administrative
12 or court proceeding, the agency may introduce the results of
13 such statistical methods as evidence of overpayment.
14 (b) Refer all physician service claims for peer review
15 when an investigation of overpayment is being conducted by the
16 agency, except as required by s. 409.913(4).
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18 Unless the agency has substantial evidence of willful fraud,
19 the first audit of any physician pursuant to this subsection
20 must be for the purposes of educating the physician regarding
21 Medicaid billing and documentation and collecting any
22 overpayments in the sample medical records.
23 (6) ADMINISTRATIVE SANCTIONS.--In determining the
24 appropriate administrative sanctions to be applied to a
25 physician, or the duration of any suspension or termination,
26 the agency shall consider the factors specified in s.
27 409.913(16). Based upon these factors, the agency may limit
28 administrative sanctions to the amount of the sample
29 overpayment.
30 Section 2. This act shall take effect October 1, 1999.
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2 SENATE SUMMARY
3 Provides legislative intent with respect to, and
guidelines for conducting, investigations of Medicaid
4 fraud and abuse. Prescribes minimum standards for peer
review. Requires certain procedures to be used in
5 determining whether overpayment has occurred. Provides
procedural safeguards for physicians under investigation.
6 Provides standards for determining sanctions for
overbilling and collecting overpayments.
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