HB 1521
1
A bill to be entitled
2An act relating to health care fraud; amending s. 400.471,
3F.S.; prohibiting the Agency for Health Care
4Administration from issuing an initial license to a home
5health agency for the purpose of opening a new home health
6agency under certain conditions until a specified date;
7prohibiting the agency from issuing a change-of-ownership
8license to a home health agency under certain conditions
9until a specified date; providing an exception; amending
10s. 400.474, F.S.; authorizing the agency to revoke a home
11health agency license if the applicant or any controlling
12interest has been sanctioned for acts specified under s.
13400.471(10), F.S.; amending s. 408.815, F.S.; revising the
14grounds upon which the agency may deny or revoke an
15application for an initial license, a change-of-ownership
16license, or a licensure renewal for certain health care
17entities listed in s. 408.802, F.S.; amending s. 409.907,
18F.S.; extending the number of years that Medicaid
19providers must retain Medicaid recipient records; adding
20additional requirements to the Medicaid provider
21agreement; revising applicability of screening
22requirements; revising conditions under which the agency
23is authorized to deny a Medicaid provider application;
24amending s. 409.912, F.S.; revising requirements for
25Medicaid prepaid, fixed-sum, and managed care contracts;
26amending s. 409.913, F.S.; removing a required element
27from the joint Medicaid fraud and abuse report submitted
28by the agency and the Medicaid Fraud Control Unit of the
29Department of Legal Affairs; extending the number of years
30that Medicaid providers must retain Medicaid recipient
31records; authorizing the Medicaid program integrity staff
32to immediately suspend or terminate a Medicaid provider
33for engaging in specified conduct; removing a requirement
34for the agency to hold suspended Medicaid payments in a
35separate account; authorizing the agency to deny payment
36or require repayment to Medicaid providers convicted of
37certain crimes; authorizing the agency to terminate a
38Medicaid provider if the provider fails to reimburse a
39fine determined by a final order; authorizing the agency
40to withhold Medicaid reimbursement to a Medicaid provider
41that fails to pay a fine determined by a final order,
42fails to enter into a repayment plan, or fails to comply
43with a repayment plan or settlement agreement; amending s.
44409.9203, F.S.; providing that certain state employees are
45ineligible from receiving a reward for reporting Medicaid
46fraud; amending s. 456.001, F.S.; defining the term
47"affiliate" or "affiliated person" as it relates to health
48professions and occupations; amending s. 456.041, F.S.;
49requiring the Department of Health to include
50administrative complaint, arrest, and any conviction
51information relating to the practitioner's profile;
52providing a disclaimer; amending s. 456.072, F.S.;
53clarifying a ground under which disciplinary actions may
54be taken; amending s. 456.073, F.S.; revising
55applicability of investigations and administrative
56complaints to include Medicaid fraud; amending s. 456.074,
57F.S.; authorizing the Department of Health to issue an
58emergency order suspending the license of any person
59licensed under ch. 456, F.S., who engages in specified
60criminal conduct; providing an effective date.
61
62Be It Enacted by the Legislature of the State of Florida:
63
64 Section 1. Subsection (11) of section 400.471, Florida
65Statutes, is amended to read:
66 400.471 Application for license; fee.-
67 (11)(a) The agency may not issue an initial license to a
68home health agency under part II of chapter 408 or this part for
69the purpose of opening a new home health agency until July 1,
702012 2010, in any county that has at least one actively licensed
71home health agency and a population of persons 65 years of age
72or older, as indicated in the most recent population estimates
73published by the Executive Office of the Governor, of fewer than
741,200 per home health agency. In such counties, for any
75application received by the agency prior to July 1, 2009, which
76has been deemed by the agency to be complete except for proof of
77accreditation, the agency may issue an initial ownership license
78only if the applicant has applied for accreditation before May
791, 2009, from an accrediting organization that is recognized by
80the agency.
81 (b) Effective October 1, 2009, the agency may not issue a
82change of ownership license to a home health agency under part
83II of chapter 408 or this part until July 1, 2012 2010, in any
84county that has at least one actively licensed home health
85agency and a population of persons 65 years of age or older, as
86indicated in the most recent population estimates published by
87the Executive Office of the Governor, of fewer than 1,200 per
88home health agency. In such counties, for any application
89received by the agency before prior to October 1, 2009, which
90has been deemed by the agency to be complete except for proof of
91accreditation, the agency may issue a change of ownership
92license only if the applicant has applied for accreditation
93before August 1, 2009, from an accrediting organization that is
94recognized by the agency. This paragraph does not apply to an
95application for a change of ownership submitted by a home health
96agency that is accredited, has been licensed by the state for at
97least 5 years, and is in good standing with the agency.
98 Section 2. Subsection (8) is added to section 400.474,
99Florida Statutes, to read:
100 400.474 Administrative penalties.-
101 (8) The agency may revoke the license of a home health
102agency that is not be eligible for licensure renewal under s.
103400.471(10).
104 Section 3. Subsection (4) of section 408.815, Florida
105Statutes, is amended, and subsection (5) is added to that
106section, to read:
107 408.815 License or application denial; revocation.-
108 (4) In addition to the grounds provided in authorizing
109statutes, the agency shall deny an application for an initial a
110license or a change-of-ownership license renewal if the
111applicant or a person having a controlling interest in an
112applicant has been:
113 (a) Has been convicted of, or enters a plea of guilty or
114nolo contendere to, regardless of adjudication, a felony under
115chapter 409, chapter 817, chapter 893, or a similar felony
116offense committed in another state or jurisdiction 21 U.S.C. ss.
117801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and any
118subsequent period of probation for such convictions or plea
119ended more than 15 years before prior to the date of the
120application;
121 (b) Has been convicted of, or enters a plea of guilty or
122nolo contendere to, regardless of adjudication, a felony under
12321 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396, unless the
124sentence and any subsequent period of probation for such
125conviction or plea ended more than 15 years before the date of
126the application;
127 (c)(b) Has been terminated for cause from the Florida
128Medicaid program pursuant to s. 409.913, unless the applicant
129has been in good standing with the Florida Medicaid program for
130the most recent 5 years; or
131 (d)(c) Has been terminated for cause, pursuant to the
132appeals procedures established by the state or Federal
133Government, from the federal Medicare program or from any other
134state Medicaid program, unless the applicant has been in good
135standing with a state Medicaid program or the federal Medicare
136program for the most recent 5 years and the termination occurred
137at least 20 years before prior to the date of the application;
138or
139 (e) Is listed on the United States Department of Health
140and Human Services Office of Inspector General's List of
141Excluded Individuals and Entities.
142 (5) In addition to the grounds provided in authorizing
143statutes, the agency shall deny an application for licensure
144renewal if the applicant or a person having a controlling
145interest in an applicant:
146 (a) Has been convicted of, or enters a plea of guilty or
147nolo contendere to, regardless of adjudication, a felony under
148chapter 409, chapter 817, chapter 893, or a similar felony
149offense committed in another state or jurisdiction since July 1,
1502009;
151 (b) Has been convicted of, or enters a plea of guilty or
152nolo contendere to, regardless of adjudication, a felony under
15321 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396 since July 1,
1542009;
155 (c) Has been terminated for cause from the Florida
156Medicaid program pursuant to s. 409.913, unless the applicant
157has been in good standing with the Florida Medicaid program for
158the most recent 5 years;
159 (d) Has been terminated for cause, pursuant to the appeals
160procedures established by the state, from any other state
161Medicaid program, unless the applicant has been in good standing
162with a state Medicaid program for the most recent 5 years and
163the termination occurred at least 20 years before the date of
164the application; or
165 (e) Is listed on the United States Department of Health
166and Human Services Office of Inspector General's List of
167Excluded Individuals and Entities.
168 Section 4. Paragraph (c) of subsection (3) of section
169409.907, Florida Statutes, is amended, paragraph (k) is added to
170that subsection, and subsection (8), paragraph (b) of subsection
171(9), and subsection (10) of that section are amended, to read:
172 409.907 Medicaid provider agreements.-The agency may make
173payments for medical assistance and related services rendered to
174Medicaid recipients only to an individual or entity who has a
175provider agreement in effect with the agency, who is performing
176services or supplying goods in accordance with federal, state,
177and local law, and who agrees that no person shall, on the
178grounds of handicap, race, color, or national origin, or for any
179other reason, be subjected to discrimination under any program
180or activity for which the provider receives payment from the
181agency.
182 (3) The provider agreement developed by the agency, in
183addition to the requirements specified in subsections (1) and
184(2), shall require the provider to:
185 (c) Retain all medical and Medicaid-related records for a
186period of 6 5 years to satisfy all necessary inquiries by the
187agency.
188 (k) Report any change of any principal of the provider,
189including any officer, director, billing agent, managing
190employee, or affiliated person, or any partner or shareholder
191who has an ownership interest equal to 5 percent or more in the
192provider. The provider must report changes to the agency no
193later than 30 days after the change occurs.
194 (8)(a) Each provider, or each principal of the provider if
195the provider is a corporation, partnership, association, or
196other entity, seeking to participate in the Medicaid program
197must submit a complete set of his or her fingerprints to the
198agency for the purpose of conducting a criminal history record
199check. Principals of the provider include any officer, director,
200billing agent, managing employee, or affiliated person, or any
201partner or shareholder who has an ownership interest equal to 5
202percent or more in the provider. However, a director of a not-
203for-profit corporation or organization is not a principal for
204purposes of a background investigation as required by this
205section if the director: serves solely in a voluntary capacity
206for the corporation or organization, does not regularly take
207part in the day-to-day operational decisions of the corporation
208or organization, receives no remuneration from the not-for-
209profit corporation or organization for his or her service on the
210board of directors, has no financial interest in the not-for-
211profit corporation or organization, and has no family members
212with a financial interest in the not-for-profit corporation or
213organization; and if the director submits an affidavit, under
214penalty of perjury, to this effect to the agency and the not-
215for-profit corporation or organization submits an affidavit,
216under penalty of perjury, to this effect to the agency as part
217of the corporation's or organization's Medicaid provider
218agreement application. Notwithstanding the above, the agency may
219require a background check for any person reasonably suspected
220by the agency to have been convicted of a crime. This subsection
221shall not apply to:
222 1. A hospital licensed under chapter 395;
223 2. A nursing home licensed under chapter 400;
224 3. A hospice licensed under chapter 400;
225 4. An assisted living facility licensed under chapter 429;
226 1.5. A unit of local government, except that requirements
227of this subsection apply to nongovernmental providers and
228entities when contracting with the local government to provide
229Medicaid services. The actual cost of the state and national
230criminal history record checks must be borne by the
231nongovernmental provider or entity; or
232 2.6. Any business that derives more than 50 percent of its
233revenue from the sale of goods to the final consumer, and the
234business or its controlling parent either is required to file a
235form 10-K or other similar statement with the Securities and
236Exchange Commission or has a net worth of $50 million or more.
237 (b) Background screening shall be conducted in accordance
238with chapter 435 and s. 408.809. The agency shall submit the
239fingerprints to the Department of Law Enforcement. The
240department shall conduct a state criminal-background
241investigation and forward the fingerprints to the Federal Bureau
242of Investigation for a national criminal-history record check.
243The cost of the state and national criminal record check shall
244be borne by the provider.
245 (c) The agency may permit a provider to participate in the
246Medicaid program pending the results of the criminal record
247check. However, such permission is fully revocable if the record
248check reveals any crime-related history as provided in
249subsection (10).
250 (c)(d) Proof of compliance with the requirements of level
2512 screening under s. 435.04 conducted within 12 months prior to
252the date that the Medicaid provider application is submitted to
253the agency shall fulfill the requirements of this subsection.
254Proof of compliance with the requirements of level 1 screening
255under s. 435.03 conducted within 12 months prior to the date
256that the Medicaid provider application is submitted to the
257agency shall meet the requirement that the Department of Law
258Enforcement conduct a state criminal history record check.
259 (9) Upon receipt of a completed, signed, and dated
260application, and completion of any necessary background
261investigation and criminal history record check, the agency must
262either:
263 (b) Deny the application if the agency finds that it is in
264the best interest of the Medicaid program to do so. The agency
265may consider any the factors listed in subsection (10), as well
266as any other factor that could affect the effective and
267efficient administration of the program, including, but not
268limited to, the applicant's demonstrated ability to provide
269services, conduct business, and operate a financially viable
270concern; the current availability of medical care, services, or
271supplies to recipients, taking into account geographic location
272and reasonable travel time; the number of providers of the same
273type already enrolled in the same geographic area; and the
274credentials, experience, success, and patient outcomes of the
275provider for the services that it is making application to
276provide in the Medicaid program. The agency shall deny the
277application if the agency finds that a provider; any officer,
278director, agent, managing employee, or affiliated person; or any
279principal, partner, or shareholder having an ownership interest
280equal to 5 percent or greater in the provider if the provider is
281a corporation, partnership, or other business entity, has failed
282to pay all outstanding fines or overpayments assessed by final
283order of the agency or final order of the Centers for Medicare
284and Medicaid Services, not subject to further appeal, unless the
285provider agrees to a repayment plan that includes withholding
286Medicaid reimbursement until the amount due is paid in full.
287 (10) The agency shall deny the application if may consider
288whether the provider, or any principal, officer, director,
289agent, managing employee, or affiliated person, or any partner
290or shareholder having an ownership interest equal to 5 percent
291or greater in the provider if the provider is a corporation,
292partnership, or other business entity, has committed an offense
293listed in s. 409.913(13), and may deny the application if one of
294these persons has:
295 (a) Made a false representation or omission of any
296material fact in making the application, including the
297submission of an application that conceals the controlling or
298ownership interest of any principal, officer, director, agent,
299managing employee, affiliated person, or partner or shareholder
300who may not be eligible to participate;
301 (b) Been or is currently excluded, suspended, terminated
302from, or has involuntarily withdrawn from participation in,
303Florida's Medicaid program or any other state's Medicaid
304program, or from participation in any other governmental or
305private health care or health insurance program;
306 (c) Been convicted of a criminal offense relating to the
307delivery of any goods or services under Medicaid or Medicare or
308any other public or private health care or health insurance
309program including the performance of management or
310administrative services relating to the delivery of goods or
311services under any such program;
312 (d) Been convicted under federal or state law of a
313criminal offense related to the neglect or abuse of a patient in
314connection with the delivery of any health care goods or
315services;
316 (c)(e) Been convicted under federal or state law of a
317criminal offense relating to the unlawful manufacture,
318distribution, prescription, or dispensing of a controlled
319substance;
320 (d)(f) Been convicted of any criminal offense relating to
321fraud, theft, embezzlement, breach of fiduciary responsibility,
322or other financial misconduct;
323 (e)(g) Been convicted under federal or state law of a
324crime punishable by imprisonment of a year or more which
325involves moral turpitude;
326 (f)(h) Been convicted in connection with the interference
327or obstruction of any investigation into any criminal offense
328listed in this subsection;
329 (g)(i) Been found to have violated federal or state laws,
330rules, or regulations governing Florida's Medicaid program or
331any other state's Medicaid program, the Medicare program, or any
332other publicly funded federal or state health care or health
333insurance program, and been sanctioned accordingly;
334 (h)(j) Been previously found by a licensing, certifying,
335or professional standards board or agency to have violated the
336standards or conditions relating to licensure or certification
337or the quality of services provided; or
338 (i)(k) Failed to pay any fine or overpayment properly
339assessed under the Medicaid program in which no appeal is
340pending or after resolution of the proceeding by stipulation or
341agreement, unless the agency has issued a specific letter of
342forgiveness or has approved a repayment schedule to which the
343provider agrees to adhere.
344 Section 5. Subsections (10) and (32) of section 409.912,
345Florida Statutes, are amended to read:
346 409.912 Cost-effective purchasing of health care.-The
347agency shall purchase goods and services for Medicaid recipients
348in the most cost-effective manner consistent with the delivery
349of quality medical care. To ensure that medical services are
350effectively utilized, the agency may, in any case, require a
351confirmation or second physician's opinion of the correct
352diagnosis for purposes of authorizing future services under the
353Medicaid program. This section does not restrict access to
354emergency services or poststabilization care services as defined
355in 42 C.F.R. part 438.114. Such confirmation or second opinion
356shall be rendered in a manner approved by the agency. The agency
357shall maximize the use of prepaid per capita and prepaid
358aggregate fixed-sum basis services when appropriate and other
359alternative service delivery and reimbursement methodologies,
360including competitive bidding pursuant to s. 287.057, designed
361to facilitate the cost-effective purchase of a case-managed
362continuum of care. The agency shall also require providers to
363minimize the exposure of recipients to the need for acute
364inpatient, custodial, and other institutional care and the
365inappropriate or unnecessary use of high-cost services. The
366agency shall contract with a vendor to monitor and evaluate the
367clinical practice patterns of providers in order to identify
368trends that are outside the normal practice patterns of a
369provider's professional peers or the national guidelines of a
370provider's professional association. The vendor must be able to
371provide information and counseling to a provider whose practice
372patterns are outside the norms, in consultation with the agency,
373to improve patient care and reduce inappropriate utilization.
374The agency may mandate prior authorization, drug therapy
375management, or disease management participation for certain
376populations of Medicaid beneficiaries, certain drug classes, or
377particular drugs to prevent fraud, abuse, overuse, and possible
378dangerous drug interactions. The Pharmaceutical and Therapeutics
379Committee shall make recommendations to the agency on drugs for
380which prior authorization is required. The agency shall inform
381the Pharmaceutical and Therapeutics Committee of its decisions
382regarding drugs subject to prior authorization. The agency is
383authorized to limit the entities it contracts with or enrolls as
384Medicaid providers by developing a provider network through
385provider credentialing. The agency may competitively bid single-
386source-provider contracts if procurement of goods or services
387results in demonstrated cost savings to the state without
388limiting access to care. The agency may limit its network based
389on the assessment of beneficiary access to care, provider
390availability, provider quality standards, time and distance
391standards for access to care, the cultural competence of the
392provider network, demographic characteristics of Medicaid
393beneficiaries, practice and provider-to-beneficiary standards,
394appointment wait times, beneficiary use of services, provider
395turnover, provider profiling, provider licensure history,
396previous program integrity investigations and findings, peer
397review, provider Medicaid policy and billing compliance records,
398clinical and medical record audits, and other factors. Providers
399shall not be entitled to enrollment in the Medicaid provider
400network. The agency shall determine instances in which allowing
401Medicaid beneficiaries to purchase durable medical equipment and
402other goods is less expensive to the Medicaid program than long-
403term rental of the equipment or goods. The agency may establish
404rules to facilitate purchases in lieu of long-term rentals in
405order to protect against fraud and abuse in the Medicaid program
406as defined in s. 409.913. The agency may seek federal waivers
407necessary to administer these policies.
408 (10) The agency shall not contract on a prepaid or fixed-
409sum basis for Medicaid services with an entity which knows or
410reasonably should know that any principal, officer, director,
411agent, managing employee, or owner of stock or beneficial
412interest in excess of 5 percent common or preferred stock, or
413the entity itself, has been found guilty of, regardless of
414adjudication, or entered a plea of nolo contendere, or guilty,
415to:
416 (a) An offense listed in s. 408.809, s. 409.913(13), or s.
417435.04 Fraud;
418 (b) Violation of federal or state antitrust statutes,
419including those proscribing price fixing between competitors and
420the allocation of customers among competitors;
421 (c) Commission of a felony involving embezzlement, theft,
422forgery, income tax evasion, bribery, falsification or
423destruction of records, making false statements, receiving
424stolen property, making false claims, or obstruction of justice;
425or
426 (d) Any crime in any jurisdiction which directly relates
427to the provision of health services on a prepaid or fixed-sum
428basis.
429 (32) Each managed care plan that is under contract with
430the agency to provide health care services to Medicaid
431recipients shall annually conduct a background check with the
432Florida Department of Law Enforcement of all persons with
433ownership interest of 5 percent or more or executive management
434responsibility for the managed care plan and shall submit to the
435agency information concerning any such person who has been found
436guilty of, regardless of adjudication, or has entered a plea of
437nolo contendere or guilty to, any of the offenses listed in s.
438408.809, s. 409.913(13), or s. 435.04 s. 435.03.
439 Section 6. Section 409.913, Florida Statutes, is amended
440to read:
441 409.913 Oversight of the integrity of the Medicaid
442program.-The agency shall operate a program to oversee the
443activities of Florida Medicaid recipients, and providers and
444their representatives, to ensure that fraudulent and abusive
445behavior and neglect of recipients occur to the minimum extent
446possible, and to recover overpayments and impose sanctions as
447appropriate. Beginning January 1, 2003, and each year
448thereafter, the agency and the Medicaid Fraud Control Unit of
449the Department of Legal Affairs shall submit a joint report to
450the Legislature documenting the effectiveness of the state's
451efforts to control Medicaid fraud and abuse and to recover
452Medicaid overpayments during the previous fiscal year. The
453report must describe the number of cases opened and investigated
454each year; the sources of the cases opened; the disposition of
455the cases closed each year; the amount of overpayments alleged
456in preliminary and final audit letters; the number and amount of
457fines or penalties imposed; any reductions in overpayment
458amounts negotiated in settlement agreements or by other means;
459the amount of final agency determinations of overpayments; the
460amount deducted from federal claiming as a result of
461overpayments; the amount of overpayments recovered each year;
462the amount of cost of investigation recovered each year; the
463average length of time to collect from the time the case was
464opened until the overpayment is paid in full; the amount
465determined as uncollectible and the portion of the uncollectible
466amount subsequently reclaimed from the Federal Government; the
467number of providers, by type, that are terminated from
468participation in the Medicaid program as a result of fraud and
469abuse; and all costs associated with discovering and prosecuting
470cases of Medicaid overpayments and making recoveries in such
471cases. The report must also document actions taken to prevent
472overpayments and the number of providers prevented from
473enrolling in or reenrolling in the Medicaid program as a result
474of documented Medicaid fraud and abuse and must include policy
475recommendations necessary to prevent or recover overpayments and
476changes necessary to prevent and detect Medicaid fraud. All
477policy recommendations in the report must include a detailed
478fiscal analysis, including, but not limited to, implementation
479costs, estimated savings to the Medicaid program, and the return
480on investment. The agency must submit the policy recommendations
481and fiscal analyses in the report to the appropriate estimating
482conference, pursuant to s. 216.137, by February 15 of each year.
483The agency and the Medicaid Fraud Control Unit of the Department
484of Legal Affairs each must include detailed unit-specific
485performance standards, benchmarks, and metrics in the report,
486including projected cost savings to the state Medicaid program
487during the following fiscal year.
488 (1) For the purposes of this section, the term:
489 (a) "Abuse" means:
490 1. Provider practices that are inconsistent with generally
491accepted business or medical practices and that result in an
492unnecessary cost to the Medicaid program or in reimbursement for
493goods or services that are not medically necessary or that fail
494to meet professionally recognized standards for health care.
495 2. Recipient practices that result in unnecessary cost to
496the Medicaid program.
497 (b) "Complaint" means an allegation that fraud, abuse, or
498an overpayment has occurred.
499 (c) "Fraud" means an intentional deception or
500misrepresentation made by a person with the knowledge that the
501deception results in unauthorized benefit to herself or himself
502or another person. The term includes any act that constitutes
503fraud under applicable federal or state law.
504 (d) "Medical necessity" or "medically necessary" means any
505goods or services necessary to palliate the effects of a
506terminal condition, or to prevent, diagnose, correct, cure,
507alleviate, or preclude deterioration of a condition that
508threatens life, causes pain or suffering, or results in illness
509or infirmity, which goods or services are provided in accordance
510with generally accepted standards of medical practice. For
511purposes of determining Medicaid reimbursement, the agency is
512the final arbiter of medical necessity. Determinations of
513medical necessity must be made by a licensed physician employed
514by or under contract with the agency and must be based upon
515information available at the time the goods or services are
516provided.
517 (e) "Overpayment" includes any amount that is not
518authorized to be paid by the Medicaid program whether paid as a
519result of inaccurate or improper cost reporting, improper
520claiming, unacceptable practices, fraud, abuse, or mistake.
521 (f) "Person" means any natural person, corporation,
522partnership, association, clinic, group, or other entity,
523whether or not such person is enrolled in the Medicaid program
524or is a provider of health care.
525 (2) The agency shall conduct, or cause to be conducted by
526contract or otherwise, reviews, investigations, analyses,
527audits, or any combination thereof, to determine possible fraud,
528abuse, overpayment, or recipient neglect in the Medicaid program
529and shall report the findings of any overpayments in audit
530reports as appropriate. At least 5 percent of all audits shall
531be conducted on a random basis. As part of its ongoing fraud
532detection activities, the agency shall identify and monitor, by
533contract or otherwise, patterns of overutilization of Medicaid
534services based on state averages. The agency shall track
535Medicaid provider prescription and billing patterns and evaluate
536them against Medicaid medical necessity criteria and coverage
537and limitation guidelines adopted by rule. Medical necessity
538determination requires that service be consistent with symptoms
539or confirmed diagnosis of illness or injury under treatment and
540not in excess of the patient's needs. The agency shall conduct
541reviews of provider exceptions to peer group norms and shall,
542using statistical methodologies, provider profiling, and
543analysis of billing patterns, detect and investigate abnormal or
544unusual increases in billing or payment of claims for Medicaid
545services and medically unnecessary provision of services.
546 (3) The agency may conduct, or may contract for,
547prepayment review of provider claims to ensure cost-effective
548purchasing; to ensure that billing by a provider to the agency
549is in accordance with applicable provisions of all Medicaid
550rules, regulations, handbooks, and policies and in accordance
551with federal, state, and local law; and to ensure that
552appropriate care is rendered to Medicaid recipients. Such
553prepayment reviews may be conducted as determined appropriate by
554the agency, without any suspicion or allegation of fraud, abuse,
555or neglect, and may last for up to 1 year. Unless the agency has
556reliable evidence of fraud, misrepresentation, abuse, or
557neglect, claims shall be adjudicated for denial or payment
558within 90 days after receipt of complete documentation by the
559agency for review. If there is reliable evidence of fraud,
560misrepresentation, abuse, or neglect, claims shall be
561adjudicated for denial of payment within 180 days after receipt
562of complete documentation by the agency for review.
563 (4) Any suspected criminal violation identified by the
564agency must be referred to the Medicaid Fraud Control Unit of
565the Office of the Attorney General for investigation. The agency
566and the Attorney General shall enter into a memorandum of
567understanding, which must include, but need not be limited to, a
568protocol for regularly sharing information and coordinating
569casework. The protocol must establish a procedure for the
570referral by the agency of cases involving suspected Medicaid
571fraud to the Medicaid Fraud Control Unit for investigation, and
572the return to the agency of those cases where investigation
573determines that administrative action by the agency is
574appropriate. Offices of the Medicaid program integrity program
575and the Medicaid Fraud Control Unit of the Department of Legal
576Affairs, shall, to the extent possible, be collocated. The
577agency and the Department of Legal Affairs shall periodically
578conduct joint training and other joint activities designed to
579increase communication and coordination in recovering
580overpayments.
581 (5) A Medicaid provider is subject to having goods and
582services that are paid for by the Medicaid program reviewed by
583an appropriate peer-review organization designated by the
584agency. The written findings of the applicable peer-review
585organization are admissible in any court or administrative
586proceeding as evidence of medical necessity or the lack thereof.
587 (6) Any notice required to be given to a provider under
588this section is presumed to be sufficient notice if sent to the
589address last shown on the provider enrollment file. It is the
590responsibility of the provider to furnish and keep the agency
591informed of the provider's current address. United States Postal
592Service proof of mailing or certified or registered mailing of
593such notice to the provider at the address shown on the provider
594enrollment file constitutes sufficient proof of notice. Any
595notice required to be given to the agency by this section must
596be sent to the agency at an address designated by rule.
597 (7) When presenting a claim for payment under the Medicaid
598program, a provider has an affirmative duty to supervise the
599provision of, and be responsible for, goods and services claimed
600to have been provided, to supervise and be responsible for
601preparation and submission of the claim, and to present a claim
602that is true and accurate and that is for goods and services
603that:
604 (a) Have actually been furnished to the recipient by the
605provider prior to submitting the claim.
606 (b) Are Medicaid-covered goods or services that are
607medically necessary.
608 (c) Are of a quality comparable to those furnished to the
609general public by the provider's peers.
610 (d) Have not been billed in whole or in part to a
611recipient or a recipient's responsible party, except for such
612copayments, coinsurance, or deductibles as are authorized by the
613agency.
614 (e) Are provided in accord with applicable provisions of
615all Medicaid rules, regulations, handbooks, and policies and in
616accordance with federal, state, and local law.
617 (f) Are documented by records made at the time the goods
618or services were provided, demonstrating the medical necessity
619for the goods or services rendered. Medicaid goods or services
620are excessive or not medically necessary unless both the medical
621basis and the specific need for them are fully and properly
622documented in the recipient's medical record.
623
624The agency shall deny payment or require repayment for goods or
625services that are not presented as required in this subsection.
626 (8) The agency shall not reimburse any person or entity
627for any prescription for medications, medical supplies, or
628medical services if the prescription was written by a physician
629or other prescribing practitioner who is not enrolled in the
630Medicaid program. This section does not apply:
631 (a) In instances involving bona fide emergency medical
632conditions as determined by the agency;
633 (b) To a provider of medical services to a patient in a
634hospital emergency department, hospital inpatient or outpatient
635setting, or nursing home;
636 (c) To bona fide pro bono services by preapproved non-
637Medicaid providers as determined by the agency;
638 (d) To prescribing physicians who are board-certified
639specialists treating Medicaid recipients referred for treatment
640by a treating physician who is enrolled in the Medicaid program;
641 (e) To prescriptions written for dually eligible Medicare
642beneficiaries by an authorized Medicare provider who is not
643enrolled in the Medicaid program;
644 (f) To other physicians who are not enrolled in the
645Medicaid program but who provide a medically necessary service
646or prescription not otherwise reasonably available from a
647Medicaid-enrolled physician; or
648 (9) A Medicaid provider shall retain medical,
649professional, financial, and business records pertaining to
650services and goods furnished to a Medicaid recipient and billed
651to Medicaid for a period of 6 5 years after the date of
652furnishing such services or goods. The agency may investigate,
653review, or analyze such records, which must be made available
654during normal business hours. However, 24-hour notice must be
655provided if patient treatment would be disrupted. The provider
656is responsible for furnishing to the agency, and keeping the
657agency informed of the location of, the provider's Medicaid-
658related records. The authority of the agency to obtain Medicaid-
659related records from a provider is neither curtailed nor limited
660during a period of litigation between the agency and the
661provider.
662 (10) Payments for the services of billing agents or
663persons participating in the preparation of a Medicaid claim
664shall not be based on amounts for which they bill nor based on
665the amount a provider receives from the Medicaid program.
666 (11) The agency shall deny payment or require repayment
667for inappropriate, medically unnecessary, or excessive goods or
668services from the person furnishing them, the person under whose
669supervision they were furnished, or the person causing them to
670be furnished.
671 (12) The complaint and all information obtained pursuant
672to an investigation of a Medicaid provider, or the authorized
673representative or agent of a provider, relating to an allegation
674of fraud, abuse, or neglect are confidential and exempt from the
675provisions of s. 119.07(1):
676 (a) Until the agency takes final agency action with
677respect to the provider and requires repayment of any
678overpayment, or imposes an administrative sanction;
679 (b) Until the Attorney General refers the case for
680criminal prosecution;
681 (c) Until 10 days after the complaint is determined
682without merit; or
683 (d) At all times if the complaint or information is
684otherwise protected by law.
685 (13) The agency shall immediately terminate participation
686of a Medicaid provider in the Medicaid program and may seek
687civil remedies or impose other administrative sanctions against
688a Medicaid provider, if the provider or any principal, officer,
689director, agent, managing employee, or affiliated person of the
690provider, or any partner or shareholder having an ownership
691interest in the provider equal to 5 percent or greater, has
692been:
693 (a) Convicted of a criminal offense related to the
694delivery of any health care goods or services, including the
695performance of management or administrative functions relating
696to the delivery of health care goods or services;
697 (b) Convicted of a criminal offense under federal law or
698the law of any state relating to the practice of the provider's
699profession; or
700 (c) Found by a court of competent jurisdiction to have
701neglected or physically abused a patient in connection with the
702delivery of health care goods or services.
703
704If the agency determines a provider did not participate or
705acquiesce in an offense specified in paragraph (a), paragraph
706(b), or paragraph (c), termination will not be imposed. If the
707agency effects a termination under this subsection, the agency
708shall issue an immediate termination final order as provided in
709subsection (16) pursuant to s. 120.569(2)(n).
710 (14) If the provider has been suspended or terminated from
711participation in the Medicaid program or the Medicare program by
712the Federal Government or any state, the agency must immediately
713suspend or terminate, as appropriate, the provider's
714participation in this state's Medicaid program for a period no
715less than that imposed by the Federal Government or any other
716state, and may not enroll such provider in this state's Medicaid
717program while such foreign suspension or termination remains in
718effect. The agency shall also immediately suspend or terminate,
719as appropriate, a provider's participation in this state's
720Medicaid program if the provider participated or acquiesced in
721any action for which any principal, officer, director, agent,
722managing employee, or affiliated person of the provider, or any
723partner or shareholder having an ownership interest in the
724provider equal to 5 percent or greater, was suspended or
725terminated from participating in the Medicaid program or the
726Medicare program by the Federal Government or any state. This
727sanction is in addition to all other remedies provided by law.
728If the agency suspends or terminates a provider's participation
729in the state's Medicaid program under this subsection, the
730agency shall issue an immediate suspension or immediate
731termination order as provided in subsection (16).
732 (15) The agency shall seek a remedy provided by law,
733including, but not limited to, any remedy provided in
734subsections (13) and (16) and s. 812.035, if:
735 (a) The provider's license has not been renewed, or has
736been revoked, suspended, or terminated, for cause, by the
737licensing agency of any state;
738 (b) The provider has failed to make available or has
739refused access to Medicaid-related records to an auditor,
740investigator, or other authorized employee or agent of the
741agency, the Attorney General, a state attorney, or the Federal
742Government;
743 (c) The provider has not furnished or has failed to make
744available such Medicaid-related records as the agency has found
745necessary to determine whether Medicaid payments are or were due
746and the amounts thereof;
747 (d) The provider has failed to maintain medical records
748made at the time of service, or prior to service if prior
749authorization is required, demonstrating the necessity and
750appropriateness of the goods or services rendered;
751 (e) The provider is not in compliance with provisions of
752Medicaid provider publications that have been adopted by
753reference as rules in the Florida Administrative Code; with
754provisions of state or federal laws, rules, or regulations; with
755provisions of the provider agreement between the agency and the
756provider; or with certifications found on claim forms or on
757transmittal forms for electronically submitted claims that are
758submitted by the provider or authorized representative, as such
759provisions apply to the Medicaid program;
760 (f) The provider or person who ordered or prescribed the
761care, services, or supplies has furnished, or ordered the
762furnishing of, goods or services to a recipient which are
763inappropriate, unnecessary, excessive, or harmful to the
764recipient or are of inferior quality;
765 (g) The provider has demonstrated a pattern of failure to
766provide goods or services that are medically necessary;
767 (h) The provider or an authorized representative of the
768provider, or a person who ordered or prescribed the goods or
769services, has submitted or caused to be submitted false or a
770pattern of erroneous Medicaid claims;
771 (i) The provider or an authorized representative of the
772provider, or a person who has ordered or prescribed the goods or
773services, has submitted or caused to be submitted a Medicaid
774provider enrollment application, a request for prior
775authorization for Medicaid services, a drug exception request,
776or a Medicaid cost report that contains materially false or
777incorrect information;
778 (j) The provider or an authorized representative of the
779provider has collected from or billed a recipient or a
780recipient's responsible party improperly for amounts that should
781not have been so collected or billed by reason of the provider's
782billing the Medicaid program for the same service;
783 (k) The provider or an authorized representative of the
784provider has included in a cost report costs that are not
785allowable under a Florida Title XIX reimbursement plan, after
786the provider or authorized representative had been advised in an
787audit exit conference or audit report that the costs were not
788allowable;
789 (l) The provider is charged by information or indictment
790with fraudulent billing practices or an offense under subsection
791(13). The sanction applied for this reason is limited to
792suspension of the provider's participation in the Medicaid
793program for the duration of the indictment unless the provider
794is found guilty pursuant to the information or indictment;
795 (m) The provider or a person who has ordered or prescribed
796the goods or services is found liable for negligent practice
797resulting in death or injury to the provider's patient;
798 (n) The provider fails to demonstrate that it had
799available during a specific audit or review period sufficient
800quantities of goods, or sufficient time in the case of services,
801to support the provider's billings to the Medicaid program;
802 (o) The provider has failed to comply with the notice and
803reporting requirements of s. 409.907;
804 (p) The agency has received reliable information of
805patient abuse or neglect or of any act prohibited by s. 409.920;
806or
807 (q) The provider has failed to comply with an agreed-upon
808repayment schedule.
809
810A provider is subject to sanctions for violations of this
811subsection as the result of actions or inactions of the
812provider, or actions or inactions of any principal, officer,
813director, agent, managing employee, or affiliated person of the
814provider, or any partner or shareholder having an ownership
815interest in the provider equal to 5 percent or greater, in which
816the provider participated or acquiesced. If the agency suspends
817or terminates a provider under this subsection, the agency shall
818issue an immediate suspension or immediate termination order as
819provided in subsection (16).
820 (16) The agency shall impose any of the following
821sanctions or disincentives on a provider or a person for any of
822the acts described in subsection (15):
823 (a) Suspension for a specific period of time of not more
824than 1 year. Suspension shall preclude participation in the
825Medicaid program, which includes any action that results in a
826claim for payment to the Medicaid program as a result of
827furnishing, supervising a person who is furnishing, or causing a
828person to furnish goods or services.
829 (b) Termination for a specific period of time of from more
830than 1 year to 20 years. Termination shall preclude
831participation in the Medicaid program, which includes any action
832that results in a claim for payment to the Medicaid program as a
833result of furnishing, supervising a person who is furnishing, or
834causing a person to furnish goods or services.
835 (c) Imposition of a fine of up to $5,000 for each
836violation. Each day that an ongoing violation continues, such as
837refusing to furnish Medicaid-related records or refusing access
838to records, is considered, for the purposes of this section, to
839be a separate violation. Each instance of improper billing of a
840Medicaid recipient; each instance of including an unallowable
841cost on a hospital or nursing home Medicaid cost report after
842the provider or authorized representative has been advised in an
843audit exit conference or previous audit report of the cost
844unallowability; each instance of furnishing a Medicaid recipient
845goods or professional services that are inappropriate or of
846inferior quality as determined by competent peer judgment; each
847instance of knowingly submitting a materially false or erroneous
848Medicaid provider enrollment application, request for prior
849authorization for Medicaid services, drug exception request, or
850cost report; each instance of inappropriate prescribing of drugs
851for a Medicaid recipient as determined by competent peer
852judgment; and each false or erroneous Medicaid claim leading to
853an overpayment to a provider is considered, for the purposes of
854this section, to be a separate violation.
855 (d) Immediate suspension, if the agency has received
856information of patient abuse or neglect, or of any act
857prohibited by s. 409.920, or any conduct listed in subsection
858(13) or subsection (14). Upon suspension, the agency must issue
859an immediate suspension final order, which shall state that the
860agency has reasonable cause to believe that the provider,
861person, or entity named is engaging in or has engaged in patient
862abuse or neglect, any act prohibited by s. 409.920, or any
863conduct listed in subsection (13) or subsection (14). The order
864shall provide notice of administrative hearing rights under ss.
865120.569 and 120.57 and is effective immediately upon notice to
866the provider, person, or entity under s. 120.569(2)(n).
867 (e) Immediate termination, if the agency has received
868information of a conviction of patient abuse or neglect, any act
869prohibited by s. 409.920, or any conduct listed in subsection
870(13) or subsection (14). Upon termination, the agency must issue
871an immediate termination order, which shall state that the
872agency has reasonable cause to believe that the provider,
873person, or entity named has been convicted of patient abuse or
874neglect, any act prohibited by s. 409.920, or any conduct listed
875in subsection (13) or subsection (14). The termination order
876shall provide notice of administrative hearing rights under ss.
877120.569 and 120.57 and is effective immediately upon notice to
878the provider, person, or entity.
879 (f)(e) A fine, not to exceed $10,000, for a violation of
880paragraph (15)(i).
881 (g)(f) Imposition of liens against provider assets,
882including, but not limited to, financial assets and real
883property, not to exceed the amount of fines or recoveries
884sought, upon entry of an order determining that such moneys are
885due or recoverable.
886 (h)(g) Prepayment reviews of claims for a specified period
887of time.
888 (i)(h) Comprehensive followup reviews of providers every 6
889months to ensure that they are billing Medicaid correctly.
890 (j)(i) Corrective-action plans that would remain in effect
891for providers for up to 3 years and that would be monitored by
892the agency every 6 months while in effect.
893 (k)(j) Other remedies as permitted by law to effect the
894recovery of a fine or overpayment.
895
896The Secretary of Health Care Administration may make a
897determination that imposition of a sanction or disincentive is
898not in the best interest of the Medicaid program, in which case
899a sanction or disincentive shall not be imposed.
900 (17) In determining the appropriate administrative
901sanction to be applied, or the duration of any suspension or
902termination, the agency shall consider:
903 (a) The seriousness and extent of the violation or
904violations.
905 (b) Any prior history of violations by the provider
906relating to the delivery of health care programs which resulted
907in either a criminal conviction or in administrative sanction or
908penalty.
909 (c) Evidence of continued violation within the provider's
910management control of Medicaid statutes, rules, regulations, or
911policies after written notification to the provider of improper
912practice or instance of violation.
913 (d) The effect, if any, on the quality of medical care
914provided to Medicaid recipients as a result of the acts of the
915provider.
916 (e) Any action by a licensing agency respecting the
917provider in any state in which the provider operates or has
918operated.
919 (f) The apparent impact on access by recipients to
920Medicaid services if the provider is suspended or terminated, in
921the best judgment of the agency.
922
923The agency shall document the basis for all sanctioning actions
924and recommendations.
925 (18) The agency may take action to sanction, suspend, or
926terminate a particular provider working for a group provider,
927and may suspend or terminate Medicaid participation at a
928specific location, rather than or in addition to taking action
929against an entire group.
930 (19) The agency shall establish a process for conducting
931followup reviews of a sampling of providers who have a history
932of overpayment under the Medicaid program. This process must
933consider the magnitude of previous fraud or abuse and the
934potential effect of continued fraud or abuse on Medicaid costs.
935 (20) In making a determination of overpayment to a
936provider, the agency must use accepted and valid auditing,
937accounting, analytical, statistical, or peer-review methods, or
938combinations thereof. Appropriate statistical methods may
939include, but are not limited to, sampling and extension to the
940population, parametric and nonparametric statistics, tests of
941hypotheses, and other generally accepted statistical methods.
942Appropriate analytical methods may include, but are not limited
943to, reviews to determine variances between the quantities of
944products that a provider had on hand and available to be
945purveyed to Medicaid recipients during the review period and the
946quantities of the same products paid for by the Medicaid program
947for the same period, taking into appropriate consideration sales
948of the same products to non-Medicaid customers during the same
949period. In meeting its burden of proof in any administrative or
950court proceeding, the agency may introduce the results of such
951statistical methods as evidence of overpayment.
952 (21) When making a determination that an overpayment has
953occurred, the agency shall prepare and issue an audit report to
954the provider showing the calculation of overpayments.
955 (22) The audit report, supported by agency work papers,
956showing an overpayment to a provider constitutes evidence of the
957overpayment. A provider may not present or elicit testimony,
958either on direct examination or cross-examination in any court
959or administrative proceeding, regarding the purchase or
960acquisition by any means of drugs, goods, or supplies; sales or
961divestment by any means of drugs, goods, or supplies; or
962inventory of drugs, goods, or supplies, unless such acquisition,
963sales, divestment, or inventory is documented by written
964invoices, written inventory records, or other competent written
965documentary evidence maintained in the normal course of the
966provider's business. Notwithstanding the applicable rules of
967discovery, all documentation that will be offered as evidence at
968an administrative hearing on a Medicaid overpayment must be
969exchanged by all parties at least 14 days before the
970administrative hearing or must be excluded from consideration.
971 (23)(a) In an audit or investigation of a violation
972committed by a provider which is conducted pursuant to this
973section, the agency is entitled to recover all investigative,
974legal, and expert witness costs if the agency's findings were
975not contested by the provider or, if contested, the agency
976ultimately prevailed.
977 (b) The agency has the burden of documenting the costs,
978which include salaries and employee benefits and out-of-pocket
979expenses. The amount of costs that may be recovered must be
980reasonable in relation to the seriousness of the violation and
981must be set taking into consideration the financial resources,
982earning ability, and needs of the provider, who has the burden
983of demonstrating such factors.
984 (c) The provider may pay the costs over a period to be
985determined by the agency if the agency determines that an
986extreme hardship would result to the provider from immediate
987full payment. Any default in payment of costs may be collected
988by any means authorized by law.
989 (24) If the agency imposes an administrative sanction
990pursuant to subsection (13), subsection (14), or subsection
991(15), except paragraphs (15)(e) and (o), upon any provider or
992any principal, officer, director, agent, managing employee, or
993affiliated person of the provider who is regulated by another
994state entity, the agency shall notify that other entity of the
995imposition of the sanction within 5 business days. Such
996notification must include the provider's or person's name and
997license number and the specific reasons for sanction.
998 (25)(a) The agency shall withhold Medicaid payments, in
999whole or in part, to a provider upon receipt of reliable
1000evidence that the circumstances giving rise to the need for a
1001withholding of payments involve fraud, willful
1002misrepresentation, or abuse under the Medicaid program, or a
1003crime committed while rendering goods or services to Medicaid
1004recipients. If the provider is not paid within 14 days after the
1005provider receives such evidence, interest shall accrue at a rate
1006of 10 percent a year. If it is determined that fraud, willful
1007misrepresentation, abuse, or a crime did not occur, the payments
1008withheld must be paid to the provider within 14 days after such
1009determination with interest at the rate of 10 percent a year.
1010Any money withheld in accordance with this paragraph shall be
1011placed in a suspended account, readily accessible to the agency,
1012so that any payment ultimately due the provider shall be made
1013within 14 days.
1014 (b) The agency shall deny payment, or require repayment,
1015if the goods or services were furnished, supervised, or caused
1016to be furnished by a person who has been convicted of a crime
1017under subsection (13) or who has been suspended or terminated
1018from the Medicaid program or Medicare program by the Federal
1019Government or any state.
1020 (c) Overpayments owed to the agency bear interest at the
1021rate of 10 percent per year from the date of determination of
1022the overpayment by the agency, and payment arrangements
1023regarding overpayments and fines must be made within 35 days
1024after the date of the termination or suspension order at the
1025conclusion of legal proceedings. A provider who does not enter
1026into or adhere to an agreed-upon repayment schedule may be
1027terminated by the agency for nonpayment or partial payment.
1028 (d) The agency, upon entry of a final agency order, a
1029judgment or order of a court of competent jurisdiction, or a
1030stipulation or settlement, may collect the moneys owed by all
1031means allowable by law, including, but not limited to, notifying
1032any fiscal intermediary of Medicare benefits that the state has
1033a superior right of payment. Upon receipt of such written
1034notification, the Medicare fiscal intermediary shall remit to
1035the state the sum claimed.
1036 (e) The agency may institute amnesty programs to allow
1037Medicaid providers the opportunity to voluntarily repay
1038overpayments. The agency may adopt rules to administer such
1039programs.
1040 (26) The agency may impose administrative sanctions
1041against a Medicaid recipient, or the agency may seek any other
1042remedy provided by law, including, but not limited to, the
1043remedies provided in s. 812.035, if the agency finds that a
1044recipient has engaged in solicitation in violation of s. 409.920
1045or that the recipient has otherwise abused the Medicaid program.
1046 (27) When the Agency for Health Care Administration has
1047made a probable cause determination and alleged that an
1048overpayment to a Medicaid provider has occurred, the agency,
1049after notice to the provider, shall:
1050 (a) Withhold, and continue to withhold during the pendency
1051of an administrative hearing pursuant to chapter 120, any
1052medical assistance reimbursement payments until such time as the
1053overpayment is recovered, unless within 30 days after receiving
1054notice thereof the provider:
1055 1. Makes repayment in full; or
1056 2. Establishes a repayment plan that is satisfactory to
1057the Agency for Health Care Administration.
1058 (b) Withhold, and continue to withhold during the pendency
1059of an administrative hearing pursuant to chapter 120, medical
1060assistance reimbursement payments if the terms of a repayment
1061plan are not adhered to by the provider.
1062 (28) Venue for all Medicaid program integrity overpayment
1063cases shall lie in Leon County, at the discretion of the agency.
1064 (29) Notwithstanding other provisions of law, the agency
1065and the Medicaid Fraud Control Unit of the Department of Legal
1066Affairs may review a provider's Medicaid-related and non-
1067Medicaid-related records in order to determine the total output
1068of a provider's practice to reconcile quantities of goods or
1069services billed to Medicaid with quantities of goods or services
1070used in the provider's total practice.
1071 (30) The agency shall terminate a provider's participation
1072in the Medicaid program if the provider fails to reimburse an
1073overpayment or fine that has been determined by termination or
1074suspension final order, not subject to further appeal, within 35
1075days after the date of the termination or suspension final
1076order, unless the provider and the agency have entered into a
1077repayment agreement.
1078 (31) If a provider requests an administrative hearing
1079pursuant to chapter 120, such hearing must be conducted within
108090 days following assignment of an administrative law judge,
1081absent exceptionally good cause shown as determined by the
1082administrative law judge or hearing officer. Upon issuance of a
1083termination or suspension final order, the outstanding balance
1084of the amount determined to constitute the overpayment or fine
1085shall become due. If a provider fails to make payments in full,
1086fails to enter into a satisfactory repayment plan, or fails to
1087comply with the terms of a repayment plan or settlement
1088agreement, the agency shall withhold medical assistance
1089reimbursement payments until the amount due is paid in full.
1090 (32) Duly authorized agents and employees of the agency
1091shall have the power to inspect, during normal business hours,
1092the records of any pharmacy, wholesale establishment, or
1093manufacturer, or any other place in which drugs and medical
1094supplies are manufactured, packed, packaged, made, stored, sold,
1095or kept for sale, for the purpose of verifying the amount of
1096drugs and medical supplies ordered, delivered, or purchased by a
1097provider. The agency shall provide at least 2 business days'
1098prior notice of any such inspection. The notice must identify
1099the provider whose records will be inspected, and the inspection
1100shall include only records specifically related to that
1101provider.
1102 (33) In accordance with federal law, Medicaid recipients
1103convicted of a crime pursuant to 42 U.S.C. s. 1320a-7b may be
1104limited, restricted, or suspended from Medicaid eligibility for
1105a period not to exceed 1 year, as determined by the agency head
1106or designee.
1107 (34) To deter fraud and abuse in the Medicaid program, the
1108agency may limit the number of Schedule II and Schedule III
1109refill prescription claims submitted from a pharmacy provider.
1110The agency shall limit the allowable amount of reimbursement of
1111prescription refill claims for Schedule II and Schedule III
1112pharmaceuticals if the agency or the Medicaid Fraud Control Unit
1113determines that the specific prescription refill was not
1114requested by the Medicaid recipient or authorized representative
1115for whom the refill claim is submitted or was not prescribed by
1116the recipient's medical provider or physician. Any such refill
1117request must be consistent with the original prescription.
1118 (35) The Office of Program Policy Analysis and Government
1119Accountability shall provide a report to the President of the
1120Senate and the Speaker of the House of Representatives on a
1121biennial basis, beginning January 31, 2006, on the agency's
1122efforts to prevent, detect, and deter, as well as recover funds
1123lost to, fraud and abuse in the Medicaid program.
1124 (36) At least three times a year, the agency shall provide
1125to each Medicaid recipient or his or her representative an
1126explanation of benefits in the form of a letter that is mailed
1127to the most recent address of the recipient on the record with
1128the Department of Children and Family Services. The explanation
1129of benefits must include the patient's name, the name of the
1130health care provider and the address of the location where the
1131service was provided, a description of all services billed to
1132Medicaid in terminology that should be understood by a
1133reasonable person, and information on how to report
1134inappropriate or incorrect billing to the agency or other law
1135enforcement entities for review or investigation. At least once
1136a year, the letter also must include information on how to
1137report criminal Medicaid fraud, the Medicaid Fraud Control
1138Unit's toll-free hotline number, and information about the
1139rewards available under s. 409.9203. The explanation of benefits
1140may not be mailed for Medicaid independent laboratory services
1141as described in s. 409.905(7) or for Medicaid certified match
1142services as described in ss. 409.9071 and 1011.70.
1143 (37) The agency shall post on its website a current list
1144of each Medicaid provider, including any principal, officer,
1145director, agent, managing employee, or affiliated person of the
1146provider, or any partner or shareholder having an ownership
1147interest in the provider equal to 5 percent or greater, who has
1148been terminated for cause from the Medicaid program or
1149sanctioned under this section. The list must be searchable by a
1150variety of search parameters and provide for the creation of
1151formatted lists that may be printed or imported into other
1152applications, including spreadsheets. The agency shall update
1153the list at least monthly.
1154 (38) In order to improve the detection of health care
1155fraud, use technology to prevent and detect fraud, and maximize
1156the electronic exchange of health care fraud information, the
1157agency shall:
1158 (a) Compile, maintain, and publish on its website a
1159detailed list of all state and federal databases that contain
1160health care fraud information and update the list at least
1161biannually;
1162 (b) Develop a strategic plan to connect all databases that
1163contain health care fraud information to facilitate the
1164electronic exchange of health information between the agency,
1165the Department of Health, the Department of Law Enforcement, and
1166the Attorney General's Office. The plan must include recommended
1167standard data formats, fraud identification strategies, and
1168specifications for the technical interface between state and
1169federal health care fraud databases;
1170 (c) Monitor innovations in health information technology,
1171specifically as it pertains to Medicaid fraud prevention and
1172detection; and
1173 (d) Periodically publish policy briefs that highlight
1174available new technology to prevent or detect health care fraud
1175and projects implemented by other states, the private sector, or
1176the Federal Government which use technology to prevent or detect
1177health care fraud.
1178 Section 7. Subsection (5) is added to section 409.9203,
1179Florida Statutes, to read:
1180 409.9203 Rewards for reporting Medicaid fraud.-
1181 (5) An employee of the Agency for Health Care
1182Administration, the Department of Legal Affairs, the Department
1183of Health, or the Department of Law Enforcement whose job
1184responsibilities include the prevention, detection, and
1185prosecution of Medicaid fraud is not eligible to receive a
1186reward under this section.
1187 Section 8. Subsection (8) is added to section 456.001,
1188Florida Statutes, to read:
1189 456.001 Definitions.-As used in this chapter, the term:
1190 (8) "Affiliate" or "affiliated person" means any person
1191who directly or indirectly manages, controls, or oversees the
1192operation of a corporation or other business entity, regardless
1193of whether that person is a partner, shareholder, owner,
1194officer, director, or agent of the entity.
1195 Section 9. Subsections (7) through (11) of section
1196456.041, Florida Statutes, are renumbered as subsections (8)
1197through (12), respectively, a new subsection (7) is added to
1198that section, and paragraph (c) of subsection (1) and
1199subsections (2) and (3) of that section are amended, to read:
1200 456.041 Practitioner profile; creation.-
1201 (1)
1202 (c) Within 30 calendar days after receiving an update of
1203information required for the practitioner's profile, the
1204department shall update the practitioner's profile in accordance
1205with the requirements of subsection (9) (7).
1206 (2) Beginning July 1, 2010, on the profile published under
1207subsection (1), the department shall include indicate if the
1208information provided under s. 456.039(1)(a)7. or s.
1209456.0391(1)(a)7. and indicate if the information is or is not
1210corroborated by a criminal history records check conducted
1211according to this subsection. The department must include in
1212each practitioner's profile the following statement: "The
1213criminal history information, if any exists, may be incomplete.
1214Federal criminal history information is not available to the
1215public." The department, or the board having regulatory
1216authority over the practitioner acting on behalf of the
1217department, shall investigate any information received by the
1218department or the board.
1219 (3) Beginning July 1, 2010, the department shall include
1220in each practitioner's profile any administrative complaint
1221filed with the department against the practitioner in which
1222probable cause has been found and the status of the complaint.
1223The Department of Health shall include in each practitioner's
1224practitioner profile that criminal information that directly
1225relates to the practitioner's ability to competently practice
1226his or her profession. The department must include in each
1227practitioner's practitioner profile the following statement:
1228"The criminal history information, if any exists, may be
1229incomplete; federal criminal history information is not
1230available to the public." The department shall provide in each
1231practitioner profile, for every final disciplinary action taken
1232against the practitioner, an easy-to-read narrative description
1233that explains the administrative complaint filed against the
1234practitioner and the final disciplinary action imposed on the
1235practitioner. The department shall include a hyperlink to each
1236final order listed in its website report of dispositions of
1237recent disciplinary actions taken against practitioners.
1238 (7) Beginning July 1, 2010, the department shall include
1239in each practitioner's profile detailed information about each
1240arrest related to that practitioner. The department must include
1241in each practitioner's profile the following statement: "The
1242arrest information, if any exists, may be incomplete."
1243 Section 10. Paragraph (kk) of subsection (1) of section
1244456.072, Florida Statutes, is amended to read:
1245 456.072 Grounds for discipline; penalties; enforcement.-
1246 (1) The following acts shall constitute grounds for which
1247the disciplinary actions specified in subsection (2) may be
1248taken:
1249 (kk) Being terminated from the state Medicaid program
1250pursuant to s. 409.913 or, any other state Medicaid program, or
1251excluded from the federal Medicare program, unless eligibility
1252to participate in the program from which the practitioner was
1253terminated has been restored.
1254 Section 11. Subsection (13) of section 456.073, Florida
1255Statutes, is amended to read:
1256 456.073 Disciplinary proceedings.-Disciplinary proceedings
1257for each board shall be within the jurisdiction of the
1258department.
1259 (13) Notwithstanding any provision of law to the contrary,
1260an administrative complaint against a licensee shall be filed
1261within 6 years after the time of the incident or occurrence
1262giving rise to the complaint against the licensee. If such
1263incident or occurrence involved fraud related to the Medicaid
1264program, criminal actions, diversion of controlled substances,
1265sexual misconduct, or impairment by the licensee, this
1266subsection does not apply to bar initiation of an investigation
1267or filing of an administrative complaint beyond the 6-year
1268timeframe. In those cases covered by this subsection in which it
1269can be shown that fraud, concealment, or intentional
1270misrepresentation of fact prevented the discovery of the
1271violation of law, the period of limitations is extended forward,
1272but in no event to exceed 12 years after the time of the
1273incident or occurrence.
1274 Section 12. Subsection (1) of section 456.074, Florida
1275Statutes, is amended to read:
1276 456.074 Certain health care practitioners; immediate
1277suspension of license.-
1278 (1) The department shall issue an emergency order
1279suspending the license of any person licensed in a profession as
1280defined in chapter 456 under chapter 458, chapter 459, chapter
1281460, chapter 461, chapter 462, chapter 463, chapter 464, chapter
1282465, chapter 466, or chapter 484 who pleads guilty to, is
1283convicted or found guilty of, or who enters a plea of nolo
1284contendere to, regardless of adjudication, to:
1285 (a) A felony under chapter 409, chapter 812, chapter 817,
1286or chapter 893, chapter 895, chapter 896, or under 21 U.S.C. ss.
1287801-970, or under 42 U.S.C. ss. 1395-1396; or
1288 (b) A misdemeanor or felony under 18 U.S.C. s. 669, ss.
1289285-287, s. 371, s. 1001, s. 1035, s. 1341, s. 1343, s. 1347, s.
12901349, or s. 1518 or 42 U.S.C. ss. 1320a-7b, relating to the
1291Medicaid program.
1292 Section 13. This act shall take effect July 1, 2010.
CODING: Words stricken are deletions; words underlined are additions.