Florida Senate - 2013 SB 844
By Senator Grimsley
21-01001-13 2013844__
1 A bill to be entitled
2 An act relating to Medicaid fraud; amending s.
3 409.907, F.S.; increasing the number of years a
4 provider must keep records; adding an additional
5 provision relating to a change in principal that must
6 be included in a Medicaid provider agreement with the
7 Agency for Health Care Administration; adding
8 definitions for “administrative fines” and
9 “outstanding overpayment”; revising provisions
10 relating to the agency’s onsite inspection
11 responsibilities; revising provisions relating to who
12 is subject to background screening; amending s.
13 409.91212, F.S.; requiring the agency to enter into an
14 interagency agreement with the Division of Insurance
15 Fraud regarding anti-fraud plans by managed care
16 plans; delaying the imposition of certain fines for
17 failing to report; amending s. 409.913, F.S.;
18 authorizing the agency to review and analyze sources
19 other than providers in order to carry out its duties
20 with respect to its Medicaid oversight
21 responsibilities; increasing the number of years a
22 provider must keep records; revising provisions
23 specifying grounds for terminating a provider from the
24 program, for seeking certain remedies for violations,
25 and for imposing certain sanctions; providing a
26 limitation on the information the agency may consider
27 when making a determination of overpayment; specifying
28 the type of records a provider must present to contest
29 an overpayment; deleting the requirement that the
30 agency pay interest on certain payments withheld from
31 a provider and revising when a provider must reimburse
32 overpayments; revising venue requirements; adding
33 provisions relating to the payment of fines; amending
34 s. 409.920, F.S.; clarifying provisions relating to
35 immunity from liability for persons who provide
36 information about Medicaid fraud; providing an
37 effective date.
38
39 Be It Enacted by the Legislature of the State of Florida:
40
41 Section 1. Paragraph (c) of subsection (3) of section
42 409.907, Florida Statutes, is amended and paragraph (k) is added
43 to that subsection, and subsections (6), (7), and (8) of that
44 section are amended to read:
45 409.907 Medicaid provider agreements.—The agency may make
46 payments for medical assistance and related services rendered to
47 Medicaid recipients only to an individual or entity who has a
48 provider agreement in effect with the agency, who is performing
49 services or supplying goods in accordance with federal, state,
50 and local law, and who agrees that no person shall, on the
51 grounds of handicap, race, color, or national origin, or for any
52 other reason, be subjected to discrimination under any program
53 or activity for which the provider receives payment from the
54 agency.
55 (3) The provider agreement developed by the agency, in
56 addition to the requirements specified in subsections (1) and
57 (2), shall require the provider to:
58 (c) Retain all medical and Medicaid-related records for 6 a
59 period of 5 years to satisfy all necessary inquiries by the
60 agency.
61 (k) Report a change in any principal of the provider,
62 including any officer, director, agent, managing employee, or
63 affiliated person, or any partner or shareholder who has an
64 ownership interest equal to 5 percent or more in the provider,
65 to the agency in writing within 30 days after the change occurs.
66 For a hospital licensed under chapter 395 or a nursing home
67 licensed under part II of chapter 400, a principal of the
68 provider is one who meets the definition of a controlling
69 interest under s. 408.803.
70 (6) A Medicaid provider agreement may be revoked, at the
71 option of the agency, due to as the result of a change of
72 ownership of any facility, association, partnership, or other
73 entity named as the provider in the provider agreement.
74 (a) If there is In the event of a change of ownership, the
75 transferor remains liable for all outstanding overpayments,
76 administrative fines, and any other moneys owed to the agency
77 before the effective date of the change of ownership. In
78 addition to the continuing liability of the transferor, The
79 transferee is also liable to the agency for all outstanding
80 overpayments identified by the agency on or before the effective
81 date of the change of ownership. For purposes of this
82 subsection, the term “outstanding overpayment” includes any
83 amount identified in a preliminary audit report issued to the
84 transferor by the agency on or before the effective date of the
85 change of ownership. In the event of a change of ownership for a
86 skilled nursing facility or intermediate care facility, the
87 Medicaid provider agreement shall be assigned to the transferee
88 if the transferee meets all other Medicaid provider
89 qualifications. In the event of a change of ownership involving
90 a skilled nursing facility licensed under part II of chapter
91 400, liability for all outstanding overpayments, administrative
92 fines, and any moneys owed to the agency before the effective
93 date of the change of ownership shall be determined in
94 accordance with s. 400.179.
95 (b) At least 60 days before the anticipated date of the
96 change of ownership, the transferor must shall notify the agency
97 of the intended change of ownership and the transferee must
98 shall submit to the agency a Medicaid provider enrollment
99 application. If a change of ownership occurs without compliance
100 with the notice requirements of this subsection, the transferor
101 and transferee are shall be jointly and severally liable for all
102 overpayments, administrative fines, and other moneys due to the
103 agency, regardless of whether the agency identified the
104 overpayments, administrative fines, or other moneys before or
105 after the effective date of the change of ownership. The agency
106 may not approve a transferee’s Medicaid provider enrollment
107 application if the transferee or transferor has not paid or
108 agreed in writing to a payment plan for all outstanding
109 overpayments, administrative fines, and other moneys due to the
110 agency. This subsection does not preclude the agency from
111 seeking any other legal or equitable remedies available to the
112 agency for the recovery of moneys owed to the Medicaid program.
113 In the event of a change of ownership involving a skilled
114 nursing facility licensed under part II of chapter 400,
115 liability for all outstanding overpayments, administrative
116 fines, and any moneys owed to the agency before the effective
117 date of the change of ownership shall be determined in
118 accordance with s. 400.179 if the Medicaid provider enrollment
119 application for change of ownership is submitted before the
120 change of ownership.
121 (c) As used in this subsection, the term:
122 1. “Administrative fines” includes any amount identified in
123 a notice of a monetary penalty or fine which has been issued by
124 the agency or other regulatory or licensing agency that governs
125 the provider.
126 2. “Outstanding overpayment” includes any amount identified
127 in a preliminary audit report issued to the transferor by the
128 agency on or before the effective date of a change of ownership.
129 (7) The agency may require, As a condition of participating
130 in the Medicaid program and before entering into the provider
131 agreement, the agency may require that the provider to submit
132 information, in an initial and any required renewal
133 applications, concerning the professional, business, and
134 personal background of the provider and permit an onsite
135 inspection of the provider’s service location by agency staff or
136 other personnel designated by the agency to perform this
137 function. Before entering into a provider agreement, the agency
138 may shall perform an a random onsite inspection, within 60 days
139 after receipt of a fully complete new provider’s application, of
140 the provider’s service location prior to making its first
141 payment to the provider for Medicaid services to determine the
142 applicant’s ability to provide the services in compliance with
143 the Medicaid program and professional regulations that the
144 applicant is proposing to provide for Medicaid reimbursement.
145 The agency is not required to perform an onsite inspection of a
146 provider or program that is licensed by the agency, that
147 provides services under waiver programs for home and community
148 based services, or that is licensed as a medical foster home by
149 the Department of Children and Family Services. As a continuing
150 condition of participation in the Medicaid program, a provider
151 must shall immediately notify the agency of any current or
152 pending bankruptcy filing. Before entering into the provider
153 agreement, or as a condition of continuing participation in the
154 Medicaid program, the agency may also require that Medicaid
155 providers reimbursed on a fee-for-services basis or fee schedule
156 basis that which is not cost-based, post a surety bond not to
157 exceed $50,000 or the total amount billed by the provider to the
158 program during the current or most recent calendar year,
159 whichever is greater. For new providers, the amount of the
160 surety bond shall be determined by the agency based on the
161 provider’s estimate of its first year’s billing. If the
162 provider’s billing during the first year exceeds the bond
163 amount, the agency may require the provider to acquire an
164 additional bond equal to the actual billing level of the
165 provider. A provider’s bond need shall not exceed $50,000 if a
166 physician or group of physicians licensed under chapter 458,
167 chapter 459, or chapter 460 has a 50 percent or greater
168 ownership interest in the provider or if the provider is an
169 assisted living facility licensed under chapter 429. The bonds
170 permitted by this section are in addition to the bonds
171 referenced in s. 400.179(2)(d). If the provider is a
172 corporation, partnership, association, or other entity, the
173 agency may require the provider to submit information concerning
174 the background of that entity and of any principal of the
175 entity, including any partner or shareholder having an ownership
176 interest in the entity equal to 5 percent or greater, and any
177 treating provider who participates in or intends to participate
178 in Medicaid through the entity. The information must include:
179 (a) Proof of holding a valid license or operating
180 certificate, as applicable, if required by the state or local
181 jurisdiction in which the provider is located or if required by
182 the Federal Government.
183 (b) Information concerning any prior violation, fine,
184 suspension, termination, or other administrative action taken
185 under the Medicaid laws or, rules, or regulations of this state
186 or of any other state or the Federal Government; any prior
187 violation of the laws or, rules, or regulations relating to the
188 Medicare program; any prior violation of the rules or
189 regulations of any other public or private insurer; and any
190 prior violation of the laws or, rules, or regulations of any
191 regulatory body of this or any other state.
192 (c) Full and accurate disclosure of any financial or
193 ownership interest that the provider, or any principal, partner,
194 or major shareholder thereof, may hold in any other Medicaid
195 provider or health care related entity or any other entity that
196 is licensed by the state to provide health or residential care
197 and treatment to persons.
198 (d) If a group provider, identification of all members of
199 the group and attestation that all members of the group are
200 enrolled in or have applied to enroll in the Medicaid program.
201 (8)(a) Each provider, or each principal of the provider if
202 the provider is a corporation, partnership, association, or
203 other entity, seeking to participate in the Medicaid program,
204 including Medicaid managed care network providers, must submit a
205 complete set of his or her fingerprints to the agency for the
206 purpose of conducting a criminal history record check.
207 Principals of the provider include any officer, director,
208 billing agent, managing employee, or affiliated person, or any
209 partner or shareholder who has an ownership interest equal to 5
210 percent or more in the provider. However, for a hospital
211 licensed under chapter 395 or a nursing home licensed under
212 chapter 400, principals of the provider are those who meet the
213 definition of a controlling interest under s. 408.803. A
214 director of a not-for-profit corporation or organization is not
215 a principal for purposes of a background investigation as
216 required by this section if the director: serves solely in a
217 voluntary capacity for the corporation or organization, does not
218 regularly take part in the day-to-day operational decisions of
219 the corporation or organization, receives no remuneration from
220 the not-for-profit corporation or organization for his or her
221 service on the board of directors, has no financial interest in
222 the not-for-profit corporation or organization, and has no
223 family members with a financial interest in the not-for-profit
224 corporation or organization; and if the director submits an
225 affidavit, under penalty of perjury, to this effect to the
226 agency and the not-for-profit corporation or organization
227 submits an affidavit, under penalty of perjury, to this effect
228 to the agency as part of the corporation’s or organization’s
229 Medicaid provider agreement application. Notwithstanding the
230 above, the agency may require a background check for any person
231 reasonably suspected by the agency to have been convicted of a
232 crime.
233 (a) This subsection does not apply to:
234 1. A hospital licensed under chapter 395;
235 2. A nursing home licensed under chapter 400;
236 3. A hospice licensed under chapter 400;
237 4. An assisted living facility licensed under chapter 429;
238 1.5. A unit of local government, except that requirements
239 of this subsection apply to nongovernmental providers and
240 entities contracting with the local government to provide
241 Medicaid services. The actual cost of the state and national
242 criminal history record checks must be borne by the
243 nongovernmental provider or entity; or
244 2.6. Any business that derives more than 50 percent of its
245 revenue from the sale of goods to the final consumer, and the
246 business or its controlling parent is required to file a form
247 10-K or other similar statement with the Securities and Exchange
248 Commission or has a net worth of $50 million or more.
249 (b) Background screening shall be conducted in accordance
250 with chapter 435 and s. 408.809. The cost of the state and
251 national criminal record check shall be borne by the provider.
252 (c) Proof of compliance with the requirements of level 2
253 screening under chapter 435 conducted within 12 months before
254 the date the Medicaid provider application is submitted to the
255 agency fulfills the requirements of this subsection.
256 Section 2. Subsections (1) and (6) of section 409.91212,
257 Florida Statutes, are amended to read:
258 409.91212 Medicaid managed care fraud.—
259 (1) Each managed care plan, as defined in s. 409.920(1)(e),
260 shall adopt an anti-fraud plan addressing the detection and
261 prevention of overpayments, abuse, and fraud relating to the
262 provision of and payment for Medicaid services and submit the
263 plan to the Office of Medicaid Program Integrity within the
264 agency for approval. The office shall enter into an interagency
265 agreement with the Division of Insurance Fraud in the Department
266 of Financial Services which delineates the responsibilities of
267 the agency in reviewing and approving anti-fraud plans for
268 entities that are also required to submit anti-fraud plans under
269 s. 626.9891. At a minimum, the anti-fraud plan must include:
270 (a) A written description or chart outlining the
271 organizational arrangement of the plan’s personnel who are
272 responsible for the investigation and reporting of possible
273 overpayment, abuse, or fraud;
274 (b) A description of the plan’s procedures for detecting
275 and investigating possible acts of fraud, abuse, and
276 overpayment;
277 (c) A description of the plan’s procedures for the
278 mandatory reporting of possible overpayment, abuse, or fraud to
279 the Office of Medicaid Program Integrity within the agency;
280 (d) A description of the plan’s program and procedures for
281 educating and training personnel on how to detect and prevent
282 fraud, abuse, and overpayment;
283 (e) The name, address, telephone number, e-mail address,
284 and fax number of the individual responsible for carrying out
285 the anti-fraud plan; and
286 (f) A summary of the results of the investigations of
287 fraud, abuse, or overpayment which were conducted during the
288 previous year by the managed care organization’s fraud
289 investigative unit.
290 (6) Each managed care plan shall report all suspected or
291 confirmed instances of provider or recipient fraud or abuse
292 within 15 calendar days after detection to the Office of
293 Medicaid Program Integrity within the agency. At a minimum the
294 report must contain the name of the provider or recipient, the
295 Medicaid billing number or tax identification number, and a
296 description of the fraudulent or abusive act. The office of
297 Medicaid Program Integrity in the agency shall forward the
298 report of suspected overpayment, abuse, or fraud to the
299 appropriate investigative unit, including, but not limited to,
300 the Bureau of Medicaid program integrity, the Medicaid fraud
301 control unit, the Division of Public Assistance Fraud, the
302 Division of Insurance Fraud, or the Department of Law
303 Enforcement.
304 (a) Failure to timely report shall result in an
305 administrative fine of $1,000 per calendar day after the 60th
306 15th day of detection.
307 (b) Failure to timely report may result in additional
308 administrative, civil, or criminal penalties.
309 Section 3. Subsections (2), (9), (13), (15), (16), (21),
310 (22), (25), (28), (29), (30) and (31) of section 409.913,
311 Florida Statutes, are amended to read:
312 409.913 Oversight of the integrity of the Medicaid
313 program.—The agency shall operate a program to oversee the
314 activities of Florida Medicaid recipients, and providers and
315 their representatives, to ensure that fraudulent and abusive
316 behavior and neglect of recipients occur to the minimum extent
317 possible, and to recover overpayments and impose sanctions as
318 appropriate. Beginning January 1, 2003, and each year
319 thereafter, the agency and the Medicaid Fraud Control Unit of
320 the Department of Legal Affairs shall submit a joint report to
321 the Legislature documenting the effectiveness of the state’s
322 efforts to control Medicaid fraud and abuse and to recover
323 Medicaid overpayments during the previous fiscal year. The
324 report must describe the number of cases opened and investigated
325 each year; the sources of the cases opened; the disposition of
326 the cases closed each year; the amount of overpayments alleged
327 in preliminary and final audit letters; the number and amount of
328 fines or penalties imposed; any reductions in overpayment
329 amounts negotiated in settlement agreements or by other means;
330 the amount of final agency determinations of overpayments; the
331 amount deducted from federal claiming as a result of
332 overpayments; the amount of overpayments recovered each year;
333 the amount of cost of investigation recovered each year; the
334 average length of time to collect from the time the case was
335 opened until the overpayment is paid in full; the amount
336 determined as uncollectible and the portion of the uncollectible
337 amount subsequently reclaimed from the Federal Government; the
338 number of providers, by type, that are terminated from
339 participation in the Medicaid program as a result of fraud and
340 abuse; and all costs associated with discovering and prosecuting
341 cases of Medicaid overpayments and making recoveries in such
342 cases. The report must also document actions taken to prevent
343 overpayments and the number of providers prevented from
344 enrolling in or reenrolling in the Medicaid program as a result
345 of documented Medicaid fraud and abuse and must include policy
346 recommendations necessary to prevent or recover overpayments and
347 changes necessary to prevent and detect Medicaid fraud. All
348 policy recommendations in the report must include a detailed
349 fiscal analysis, including, but not limited to, implementation
350 costs, estimated savings to the Medicaid program, and the return
351 on investment. The agency must submit the policy recommendations
352 and fiscal analyses in the report to the appropriate estimating
353 conference, pursuant to s. 216.137, by February 15 of each year.
354 The agency and the Medicaid Fraud Control Unit of the Department
355 of Legal Affairs each must include detailed unit-specific
356 performance standards, benchmarks, and metrics in the report,
357 including projected cost savings to the state Medicaid program
358 during the following fiscal year.
359 (2) The agency shall conduct, or cause to be conducted by
360 contract or otherwise, reviews, investigations, analyses,
361 audits, or any combination thereof, to determine possible fraud,
362 abuse, overpayment, or recipient neglect in the Medicaid program
363 and shall report the findings of any overpayments in audit
364 reports as appropriate. At least 5 percent of all audits must
365 shall be conducted on a random basis. As part of its ongoing
366 fraud detection activities, the agency shall identify and
367 monitor, by contract or otherwise, patterns of overutilization
368 of Medicaid services based on state averages. The agency shall
369 track Medicaid provider prescription and billing patterns and
370 evaluate them against Medicaid medical necessity criteria and
371 coverage and limitation guidelines adopted by rule. Medical
372 necessity determination requires that service be consistent with
373 symptoms or confirmed diagnosis of illness or injury under
374 treatment and not in excess of the patient’s needs. The agency
375 shall conduct reviews of provider exceptions to peer group norms
376 and shall, using statistical methodologies, provider profiling,
377 and analysis of billing patterns, shall detect and investigate
378 abnormal or unusual increases in billing or payment of claims
379 for Medicaid services and medically unnecessary provision of
380 services. The agency may review and analyze information from
381 sources other than enrolled Medicaid providers in conducting its
382 activities under this subsection.
383 (9) A Medicaid provider shall retain medical, professional,
384 financial, and business records pertaining to services and goods
385 furnished to a Medicaid recipient and billed to Medicaid for 6 a
386 period of 5 years after the date of furnishing such services or
387 goods. The agency may investigate, review, or analyze such
388 records, which must be made available during normal business
389 hours. However, 24-hour notice must be provided if patient
390 treatment would be disrupted. The provider must keep is
391 responsible for furnishing to the agency, and keeping the agency
392 informed of the location of, the provider’s Medicaid-related
393 records. The authority of the agency to obtain Medicaid-related
394 records from a provider is neither curtailed nor limited during
395 a period of litigation between the agency and the provider.
396 (13) The agency shall immediately terminate participation
397 of a Medicaid provider in the Medicaid program and may seek
398 civil remedies or impose other administrative sanctions against
399 a Medicaid provider, if the provider or any principal, officer,
400 director, agent, managing employee, or affiliated person of the
401 provider, or any partner or shareholder having an ownership
402 interest in the provider equal to 5 percent or greater, has been
403 convicted of a criminal offense under federal law or the law of
404 any state relating to the practice of the provider’s profession,
405 or a criminal offense listed under s. 409.907(10), s.
406 408.809(4), or s. 435.04(2) has been:
407 (a) Convicted of a criminal offense related to the delivery
408 of any health care goods or services, including the performance
409 of management or administrative functions relating to the
410 delivery of health care goods or services;
411 (b) Convicted of a criminal offense under federal law or
412 the law of any state relating to the practice of the provider’s
413 profession; or
414 (c) Found by a court of competent jurisdiction to have
415 neglected or physically abused a patient in connection with the
416 delivery of health care goods or services. If the agency
417 determines that the a provider did not participate or acquiesce
418 in the an offense specified in paragraph (a), paragraph (b), or
419 paragraph (c), termination will not be imposed. If the agency
420 effects a termination under this subsection, the agency shall
421 take final action issue an immediate final order pursuant to s.
422 120.569(2)(n).
423 (15) The agency shall seek a remedy provided by law,
424 including, but not limited to, any remedy provided in
425 subsections (13) and (16) and s. 812.035, if:
426 (a) The provider’s license has not been renewed, or has
427 been revoked, suspended, or terminated, for cause, by the
428 licensing agency of any state;
429 (b) The provider has failed to make available or has
430 refused access to Medicaid-related records to an auditor,
431 investigator, or other authorized employee or agent of the
432 agency, the Attorney General, a state attorney, or the Federal
433 Government;
434 (c) The provider has not furnished or has failed to make
435 available such Medicaid-related records as the agency has found
436 necessary to determine whether Medicaid payments are or were due
437 and the amounts thereof;
438 (d) The provider has failed to maintain medical records
439 made at the time of service, or prior to service if prior
440 authorization is required, demonstrating the necessity and
441 appropriateness of the goods or services rendered;
442 (e) The provider is not in compliance with provisions of
443 Medicaid provider publications that have been adopted by
444 reference as rules in the Florida Administrative Code; with
445 provisions of state or federal laws, rules, or regulations; with
446 provisions of the provider agreement between the agency and the
447 provider; or with certifications found on claim forms or on
448 transmittal forms for electronically submitted claims that are
449 submitted by the provider or authorized representative, as such
450 provisions apply to the Medicaid program;
451 (f) The provider or person who ordered, authorized, or
452 prescribed the care, services, or supplies has furnished, or
453 ordered or authorized the furnishing of, goods or services to a
454 recipient which are inappropriate, unnecessary, excessive, or
455 harmful to the recipient or are of inferior quality;
456 (g) The provider has demonstrated a pattern of failure to
457 provide goods or services that are medically necessary;
458 (h) The provider or an authorized representative of the
459 provider, or a person who ordered, authorized, or prescribed the
460 goods or services, has submitted or caused to be submitted false
461 or a pattern of erroneous Medicaid claims;
462 (i) The provider or an authorized representative of the
463 provider, or a person who has ordered, authorized, or prescribed
464 the goods or services, has submitted or caused to be submitted a
465 Medicaid provider enrollment application, a request for prior
466 authorization for Medicaid services, a drug exception request,
467 or a Medicaid cost report that contains materially false or
468 incorrect information;
469 (j) The provider or an authorized representative of the
470 provider has collected from or billed a recipient or a
471 recipient’s responsible party improperly for amounts that should
472 not have been so collected or billed by reason of the provider’s
473 billing the Medicaid program for the same service;
474 (k) The provider or an authorized representative of the
475 provider has included in a cost report costs that are not
476 allowable under a Florida Title XIX reimbursement plan, after
477 the provider or authorized representative had been advised in an
478 audit exit conference or audit report that the costs were not
479 allowable;
480 (l) The provider is charged by information or indictment
481 with fraudulent billing practices or an offense referenced in
482 subsection (13). The sanction applied for this reason is limited
483 to suspension of the provider’s participation in the Medicaid
484 program for the duration of the indictment unless the provider
485 is found guilty pursuant to the information or indictment;
486 (m) The provider or a person who has ordered, authorized,
487 or prescribed the goods or services is found liable for
488 negligent practice resulting in death or injury to the
489 provider’s patient;
490 (n) The provider fails to demonstrate that it had available
491 during a specific audit or review period sufficient quantities
492 of goods, or sufficient time in the case of services, to support
493 the provider’s billings to the Medicaid program;
494 (o) The provider has failed to comply with the notice and
495 reporting requirements of s. 409.907;
496 (p) The agency has received reliable information of patient
497 abuse or neglect or of any act prohibited by s. 409.920; or
498 (q) The provider has failed to comply with an agreed-upon
499 repayment schedule.
500
501 A provider is subject to sanctions for violations of this
502 subsection as the result of actions or inactions of the
503 provider, or actions or inactions of any principal, officer,
504 director, agent, managing employee, or affiliated person of the
505 provider, or any partner or shareholder having an ownership
506 interest in the provider equal to 5 percent or greater, in which
507 the provider participated or acquiesced.
508 (16) The agency shall impose any of the following sanctions
509 or disincentives on a provider or a person for any of the acts
510 described in subsection (15):
511 (a) Suspension for a specific period of time of not more
512 than 1 year. Suspension precludes shall preclude participation
513 in the Medicaid program, which includes any action that results
514 in a claim for payment to the Medicaid program for as a result
515 of furnishing, supervising a person who is furnishing, or
516 causing a person to furnish goods or services.
517 (b) Termination for a specific period of time ranging of
518 from more than 1 year to 20 years. Termination precludes shall
519 preclude participation in the Medicaid program, which includes
520 any action that results in a claim for payment to the Medicaid
521 program for as a result of furnishing, supervising a person who
522 is furnishing, or causing a person to furnish goods or services.
523 (c) Imposition of a fine of up to $5,000 for each
524 violation. Each day that an ongoing violation continues, such as
525 refusing to furnish Medicaid-related records or refusing access
526 to records, is considered, for the purposes of this section, to
527 be a separate violation. Each instance of improper billing of a
528 Medicaid recipient; each instance of including an unallowable
529 cost on a hospital or nursing home Medicaid cost report after
530 the provider or authorized representative has been advised in an
531 audit exit conference or previous audit report of the cost
532 unallowability; each instance of furnishing a Medicaid recipient
533 goods or professional services that are inappropriate or of
534 inferior quality as determined by competent peer judgment; each
535 instance of knowingly submitting a materially false or erroneous
536 Medicaid provider enrollment application, request for prior
537 authorization for Medicaid services, drug exception request, or
538 cost report; each instance of inappropriate prescribing of drugs
539 for a Medicaid recipient as determined by competent peer
540 judgment; and each false or erroneous Medicaid claim leading to
541 an overpayment to a provider is considered, for the purposes of
542 this section, to be a separate violation.
543 (d) Immediate suspension, if the agency has received
544 information of patient abuse or neglect or of any act prohibited
545 by s. 409.920. Upon suspension, the agency must issue an
546 immediate final order under s. 120.569(2)(n).
547 (e) A fine, not to exceed $10,000, for a violation of
548 paragraph (15)(i).
549 (f) Imposition of liens against provider assets, including,
550 but not limited to, financial assets and real property, not to
551 exceed the amount of fines or recoveries sought, upon entry of
552 an order determining that such moneys are due or recoverable.
553 (g) Prepayment reviews of claims for a specified period of
554 time.
555 (h) Comprehensive followup reviews of providers every 6
556 months to ensure that they are billing Medicaid correctly.
557 (i) Corrective-action plans that would remain in effect for
558 providers for up to 3 years and that are would be monitored by
559 the agency every 6 months while in effect.
560 (j) Other remedies as permitted by law to effect the
561 recovery of a fine or overpayment.
562
563 If a provider voluntarily relinquishes its Medicaid provider
564 number or an associated license, or allows the associated
565 licensure to expire after receiving written notice that the
566 agency is conducting, or has conducted, an audit, survey,
567 inspection, or investigation and that a sanction of suspension
568 or termination will or would be imposed for noncompliance
569 discovered as a result of the audit, survey, inspection, or
570 investigation, the agency shall impose the sanction of
571 termination for cause against the provider. The Secretary of
572 Health Care Administration may make a determination that
573 imposition of a sanction or disincentive is not in the best
574 interest of the Medicaid program, in which case a sanction or
575 disincentive may shall not be imposed.
576 (21) When making a determination that an overpayment has
577 occurred, the agency shall prepare and issue an audit report to
578 the provider showing the calculation of overpayments. The
579 agency’s determination must be based solely upon information
580 available to it before issuance of the audit report and, in the
581 case of documentation obtained to substantiate claims for
582 Medicaid reimbursement, based solely upon contemporaneous
583 records.
584 (22) The audit report, supported by agency work papers,
585 showing an overpayment to a provider constitutes evidence of the
586 overpayment. A provider may not present or elicit testimony,
587 either on direct examination or cross-examination in any court
588 or administrative proceeding, regarding the purchase or
589 acquisition by any means of drugs, goods, or supplies; sales or
590 divestment by any means of drugs, goods, or supplies; or
591 inventory of drugs, goods, or supplies, unless such acquisition,
592 sales, divestment, or inventory is documented by written
593 invoices, written inventory records, or other competent written
594 documentary evidence maintained in the normal course of the
595 provider’s business. A provider may not present records to
596 contest an overpayment or sanction unless such records are
597 contemporaneous and, if requested during the audit process, were
598 furnished to the agency or its agent upon request or were
599 furnished within 30 days after the provider received the final
600 audit report. This limitation does not apply to Medicaid cost
601 report audits. Notwithstanding the applicable rules of
602 discovery, all documentation to that will be offered as evidence
603 at an administrative hearing on a Medicaid overpayment or an
604 administrative sanction must be exchanged by all parties at
605 least 14 days before the administrative hearing or must be
606 excluded from consideration.
607 (25)(a) The agency shall withhold Medicaid payments, in
608 whole or in part, to a provider upon receipt of reliable
609 evidence that the circumstances giving rise to the need for a
610 withholding of payments involve fraud, willful
611 misrepresentation, or abuse under the Medicaid program, or a
612 crime committed while rendering goods or services to Medicaid
613 recipients. If it is determined that fraud, willful
614 misrepresentation, abuse, or a crime did not occur, the payments
615 withheld must be paid to the provider within 14 days after such
616 determination with interest at the rate of 10 percent a year.
617 Any money withheld in accordance with this paragraph shall be
618 placed in a suspended account, readily accessible to the agency,
619 so that any payment ultimately due the provider shall be made
620 within 14 days.
621 (b) The agency shall deny payment, or require repayment, if
622 the goods or services were furnished, supervised, or caused to
623 be furnished by a person who has been suspended or terminated
624 from the Medicaid program or Medicare program by the Federal
625 Government or any state.
626 (c) Overpayments owed to the agency bear interest at the
627 rate of 10 percent per year from the date of determination of
628 the overpayment by the agency, and payment arrangements must be
629 made within 30 days after the date of the final order and are
630 not subject to further appeal at the conclusion of legal
631 proceedings. A provider who does not enter into or adhere to an
632 agreed-upon repayment schedule may be terminated by the agency
633 for nonpayment or partial payment.
634 (d) The agency, upon entry of a final agency order, a
635 judgment or order of a court of competent jurisdiction, or a
636 stipulation or settlement, may collect the moneys owed by all
637 means allowable by law, including, but not limited to, notifying
638 any fiscal intermediary of Medicare benefits that the state has
639 a superior right of payment. Upon receipt of such written
640 notification, the Medicare fiscal intermediary shall remit to
641 the state the sum claimed.
642 (e) The agency may institute amnesty programs to allow
643 Medicaid providers the opportunity to voluntarily repay
644 overpayments. The agency may adopt rules to administer such
645 programs.
646 (28) Venue for all Medicaid program integrity overpayment
647 cases lies shall lie in Leon County, at the discretion of the
648 agency.
649 (29) Notwithstanding other provisions of law, the agency
650 and the Medicaid Fraud Control Unit of the Department of Legal
651 Affairs may review a person’s or provider’s Medicaid-related and
652 non-Medicaid-related records in order to determine the total
653 output of a provider’s practice to reconcile quantities of goods
654 or services billed to Medicaid with quantities of goods or
655 services used in the provider’s total practice.
656 (30) The agency shall terminate a provider’s participation
657 in the Medicaid program if the provider fails to reimburse an
658 overpayment or pay an agency-imposed fine that has been
659 determined by final order, not subject to further appeal, within
660 30 35 days after the date of the final order, unless the
661 provider and the agency have entered into a repayment agreement.
662 (31) If a provider requests an administrative hearing
663 pursuant to chapter 120, such hearing must be conducted within
664 90 days following assignment of an administrative law judge,
665 absent exceptionally good cause shown as determined by the
666 administrative law judge or hearing officer. Upon issuance of a
667 final order, the outstanding balance of the amount determined to
668 constitute the overpayment and fines is shall become due. If a
669 provider fails to make payments in full, fails to enter into a
670 satisfactory repayment plan, or fails to comply with the terms
671 of a repayment plan or settlement agreement, the agency shall
672 withhold medical assistance reimbursement payments for Medicaid
673 services until the amount due is paid in full.
674 Section 4. Subsection (8) of section 409.920, Florida
675 Statutes, is amended to read:
676 409.920 Medicaid provider fraud.—
677 (8) A person who provides the state, any state agency, any
678 of the state’s political subdivisions, or any agency of the
679 state’s political subdivisions with information about fraud or
680 suspected fraudulent acts fraud by a Medicaid provider,
681 including a managed care organization, is immune from civil
682 liability for libel, slander, or any other relevant tort for
683 providing the information about fraud or suspected fraudulent
684 acts, unless the person acted with knowledge that the
685 information was false or with reckless disregard for the truth
686 or falsity of the information. Such immunity extends to reports
687 of fraudulent acts or suspected fraudulent acts conveyed to or
688 from the agency in any manner, including any forum and with any
689 audience as directed by the agency, and includes all discussions
690 subsequent to the report and subsequent inquiries from the
691 agency, unless the person acted with knowledge that the
692 information was false or with reckless disregard for the truth
693 or falsity of the information. For purposes of this subsection,
694 the term “fraudulent acts” includes actual or suspected fraud
695 and abuse, insurance fraud, licensure fraud, or public
696 assistance fraud, including any fraud-related matters that a
697 provider or health plan is required to report to the agency or a
698 law enforcement agency.
699 Section 5. This act shall take effect July 1, 2013.