Bill Text: FL S0752 | 2010 | Regular Session | Engrossed

---

Bill Title: Health Care [SPSC]

Sponsorship: Partisan Bill (Republican 1)

Status: (Failed) 2010-04-30 - Died in Messages, companion bill(s) passed, see HB 5311 (Ch. 2010-161), CS/HB 7069 (Ch. 2010-114) [S0752 Detail]

Download: Florida-2010-S0752-Engrossed.html

---

 
CS for CS for CS for SB 752                      First Engrossed 
2010752e1 
1                        A bill to be entitled 
2         An act relating to health care; amending s. 400.471, 
3         F.S.; prohibiting the Agency for Health Care 
4         Administration from issuing an initial license to a 
5         home health agency for the purpose of opening a new 
6         home health agency under certain conditions until a 
7         specified date; prohibiting the agency from issuing a 
8         change-of-ownership license to a home health agency 
9         under certain conditions until a specified date; 
10         providing an exception; amending s. 400.474, F.S.; 
11         authorizing the agency to revoke a home health agency 
12         license if the applicant or any controlling interest 
13         has been sanctioned for acts specified under s. 
14         400.471(10), F.S.; amending s. 400.9905, F.S.; 
15         specifying that certain licensure requirements do not 
16         apply to certain pediatric cardiological or 
17         perinatological clinical facilities; providing that 
18         part X of ch. 400, F.S., the Health Care Clinic Act, 
19         does not apply to entities owned by a corporation that 
20         has a specified amount of annual sales of health care 
21         services under certain circumstances; amending s. 
22         408.815, F.S.; revising the grounds upon which the 
23         agency may deny or revoke an application for an 
24         initial license, a change-of-ownership license, or a 
25         licensure renewal for certain health care entities 
26         listed in s. 408.802, F.S.; amending s. 408.910, F.S.; 
27         revising the list of employers who are eligible to 
28         enroll in the Florida Health Choices Program; revising 
29         the membership of the board of directors of the 
30         Florida Health Choices, Inc.; requiring the President 
31         of the Senate and the Speaker of the House of 
32         Representatives to initially appoint members to the 
33         board of directors for staggered terms; requiring that 
34         the members of the board appoint new members to the 
35         board of directors after a specified date, subject to 
36         Senate confirmation; deleting a provision that 
37         prohibits board members from serving for more than a 
38         certain number of consecutive years; amending s. 
39         409.907, F.S.; extending the number of years that 
40         Medicaid providers must retain Medicaid recipient 
41         records; adding additional requirements to the 
42         Medicaid provider agreement; revising applicability of 
43         screening requirements; revising conditions under 
44         which the agency is authorized to deny a Medicaid 
45         provider application; amending s. 409.912, F.S.; 
46         revising requirements for Medicaid prepaid, fixed-sum, 
47         and managed care contracts; revising requirements for 
48         Medicaid durable medical equipment providers; 
49         repealing s. 409.9122(13), F.S., relating to the 
50         enrollee assignment process of Medicaid managed 
51         prepaid health plans for those Medicaid managed 
52         prepaid health plans operating in Miami-Dade County; 
53         amending s. 409.913, F.S.; removing a required element 
54         from the joint Medicaid fraud and abuse report 
55         submitted by the agency and the Medicaid Fraud Control 
56         Unit of the Department of Legal Affairs; extending the 
57         number of years that Medicaid providers must retain 
58         Medicaid recipient records; authorizing the Medicaid 
59         program integrity staff to immediately suspend or 
60         terminate a Medicaid provider for engaging in 
61         specified conduct; removing a requirement for the 
62         agency to hold suspended Medicaid payments in a 
63         separate account; authorizing the agency to deny 
64         payment or require repayment to Medicaid providers 
65         convicted of certain crimes; authorizing the agency to 
66         terminate a Medicaid provider if the provider fails to 
67         reimburse a fine determined by a final order; 
68         authorizing the agency to withhold Medicaid 
69         reimbursement to a Medicaid provider that fails to pay 
70         a fine determined by a final order, fails to enter 
71         into a repayment plan, or fails to comply with a 
72         repayment plan or settlement agreement; requiring the 
73         biennial review of Medicaid fraud and abuse by the 
74         Office of Program Policy Analysis and Government 
75         Accountability to include a report on the Medicaid 
76         Fraud Control Unit within the Department of Legal 
77         Affairs; amending s. 409.9203, F.S.; providing that 
78         certain state employees are ineligible from receiving 
79         a reward for reporting Medicaid fraud; amending s. 
80         456.001, F.S.; defining the term “affiliate” or 
81         “affiliated person” as it relates to health 
82         professions and occupations; amending s. 456.041, 
83         F.S.; requiring the Department of Health to include 
84         administrative complaints and any conviction 
85         information relating to the practitioner’s profile; 
86         providing a disclaimer; amending s. 456.0635, F.S.; 
87         revising the grounds under which the Department of 
88         Health or corresponding board is required to refuse to 
89         admit a candidate to an examination and refuse to 
90         issue or renew a license, certificate, or registration 
91         of a health care practitioner; providing an exception; 
92         amending s. 456.072, F.S.; clarifying a ground under 
93         which disciplinary actions may be taken; amending s. 
94         456.073, F.S.; revising applicability of 
95         investigations and administrative complaints to 
96         include Medicaid fraud; amending s. 456.074, F.S.; 
97         authorizing the Department of Health to issue an 
98         emergency order suspending the license of any person 
99         licensed under ch. 456, F.S., who engages in specified 
100         criminal conduct; amending s. 499.01, F.S.; exempting 
101         certain persons from requirements for medical device 
102         manufacturer permits; providing an effective date. 
103 
104  Be It Enacted by the Legislature of the State of Florida: 
105 
106         Section 1. Subsection (11) of section 400.471, Florida 
107  Statutes, is amended to read: 
108         400.471 Application for license; fee.— 
109         (11)(a) The agency may not issue an initial license to a 
110  home health agency under part II of chapter 408 or this part for 
111  the purpose of opening a new home health agency until July 1, 
112  2012 2010, in any county that has at least one actively licensed 
113  home health agency and a population of persons 65 years of age 
114  or older, as indicated in the most recent population estimates 
115  published by the Executive Office of the Governor, of fewer than 
116  1,200 per home health agency. In such counties, for any 
117  application received by the agency prior to July 1, 2009, which 
118  has been deemed by the agency to be complete except for proof of 
119  accreditation, the agency may issue an initial ownership license 
120  only if the applicant has applied for accreditation before May 
121  1, 2009, from an accrediting organization that is recognized by 
122  the agency. 
123         (b) Effective October 1, 2009, the agency may not issue a 
124  change of ownership license to a home health agency under part 
125  II of chapter 408 or this part until July 1, 2012 2010, in any 
126  county that has at least one actively licensed home health 
127  agency and a population of persons 65 years of age or older, as 
128  indicated in the most recent population estimates published by 
129  the Executive Office of the Governor, of fewer than 1,200 per 
130  home health agency. In such counties, for any application 
131  received by the agency before prior to October 1, 2009, which 
132  has been deemed by the agency to be complete except for proof of 
133  accreditation, the agency may issue a change of ownership 
134  license only if the applicant has applied for accreditation 
135  before August 1, 2009, from an accrediting organization that is 
136  recognized by the agency. This paragraph does not apply to an 
137  application for a change in ownership from an existing home 
138  health agency that is accredited, has been licensed by the state 
139  at least 5 years, and is in good standing with the agency. 
140         Section 2. Subsection (8) is added to section 400.474, 
141  Florida Statutes, to read: 
142         400.474 Administrative penalties.— 
143         (8) The agency may revoke the license of a home health 
144  agency that is not eligible for licensure renewal under s. 
145  400.471(10). 
146         Section 3. Paragraph (l) of subsection (4) of section 
147  400.9905, Florida Statutes, is amended, and paragraph (m) is 
148  added to that subsection, to read: 
149         400.9905 Definitions.— 
150         (4) “Clinic” means an entity at which health care services 
151  are provided to individuals and which tenders charges for 
152  reimbursement for such services, including a mobile clinic and a 
153  portable equipment provider. For purposes of this part, the term 
154  does not include and the licensure requirements of this part do 
155  not apply to: 
156         (l) Orthotic, or prosthetic, pediatric cardiological, or 
157  perinatological clinical facilities that are a publicly traded 
158  corporation or that are wholly owned, directly or indirectly, by 
159  a publicly traded corporation. As used in this paragraph, a 
160  publicly traded corporation is a corporation that issues 
161  securities traded on an exchange registered with the United 
162  States Securities and Exchange Commission as a national 
163  securities exchange. 
164         (m) Entities that are owned by a corporation that has $250 
165  million or more in total annual sales of health care services 
166  provided by licensed health care practitioners if one or more of 
167  the owners of the entity is a health care practitioner who is 
168  licensed in this state, is responsible for supervising the 
169  business activities of the entity, and is legally responsible 
170  for the entity’s compliance with state law for purposes of this 
171  section. 
172         Section 4. Subsections (1) and (4) of section 408.815, 
173  Florida Statutes, are amended, and subsection (5) is added to 
174  that section, to read: 
175         408.815 License or application denial; revocation.— 
176         (1) In addition to the grounds provided in authorizing 
177  statutes, grounds that may be used by the agency for denying and 
178  revoking a license or change of ownership application include 
179  any of the following actions by a controlling interest: 
180         (a) False representation of a material fact in the license 
181  application or omission of any material fact from the 
182  application. 
183         (b) An intentional or negligent act materially affecting 
184  the health or safety of a client of the provider. 
185         (c) A violation of this part, authorizing statutes, or 
186  applicable rules. 
187         (d) A demonstrated pattern of deficient performance. 
188         (e) The applicant, licensee, or controlling interest has 
189  been or is currently excluded, suspended, or terminated from 
190  participation in the state Medicaid program, the Medicaid 
191  program of any other state, or the Medicare program. 
192         (f) The applicant, licensee, or controlling interest is or 
193  was an administrator or controlling interest in a facility or 
194  entity during the period an event that caused or contributed to 
195  the facility or entity being excluded, suspended, or terminated 
196  from participation in the state Medicaid program, the Medicaid 
197  program of any other state, or the Medicare program. 
198         (4) In addition to the grounds provided in authorizing 
199  statutes, the agency shall deny an application for an initial a 
200  license or a change-of-ownership license renewal if the 
201  applicant or a person having a controlling interest in the an 
202  applicant has been: 
203         (a) Has been convicted of, or entered enters a plea of 
204  guilty or nolo contendere to, regardless of adjudication, a 
205  felony under chapter 409, chapter 817, chapter 893, or a similar 
206  felony offense committed in another state or jurisdiction 21 
207  U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the 
208  sentence and any subsequent period of probation for such 
209  conviction convictions or plea ended more than 15 years before 
210  prior to the date of the application; 
211         (b) Has been convicted of, or entered a plea of guilty or 
212  nolo contendere to, regardless of adjudication, a felony under 
213  21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the 
214  sentence and any subsequent period of probation for such 
215  conviction or plea ended more than 15 years before the date of 
216  the application; 
217         (c)(b) Has been terminated for cause from the Florida 
218  Medicaid program pursuant to s. 409.913, unless the applicant 
219  has been in good standing with the Florida Medicaid program for 
220  the most recent 5 years; or 
221         (d)(c) Has been terminated for cause, pursuant to the 
222  appeals procedures established by the state, or Federal 
223  Government, from the federal Medicare program or from any other 
224  state Medicaid program, unless the applicant has been in good 
225  standing with a state Medicaid program or the federal Medicare 
226  program for the most recent 5 years and the termination occurred 
227  at least 20 years before prior to the date of the application; 
228  or. 
229         (e) Is currently listed on the United States Department of 
230  Health and Human Services Office of Inspector General’s List of 
231  Excluded Individuals and Entities. 
232         (5) In addition to the grounds provided in authorizing 
233  statutes, the agency shall deny an application for licensure 
234  renewal if the applicant or a person having a controlling 
235  interest in the applicant: 
236         (a) Has been convicted of, or entered a plea of guilty or 
237  nolo contendere to, regardless of adjudication, a felony under 
238  chapter 409, chapter 817, chapter 893, or a similar felony 
239  offense committed in another state or jurisdiction since July 1, 
240  2009; 
241         (b) Has been convicted of, or entered a plea of guilty or 
242  nolo contendere to, regardless of adjudication, a felony under 
243  21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396 since July 1, 
244  2009; 
245         (c) Has been terminated for cause from the Florida Medicaid 
246  program pursuant to s. 409.913, unless the applicant has been in 
247  good standing with the Florida Medicaid program for the most 
248  recent 5 years; 
249         (d) Has been terminated for cause, pursuant to the appeals 
250  procedures established by the state, from any other state 
251  Medicaid program, unless the applicant has been in good standing 
252  with a state Medicaid program for the most recent 5 years and 
253  the termination occurred at least 20 years before the date of 
254  the application; or 
255         (e) Is currently listed on the United States Department of 
256  Health and Human Services Office of Inspector General’s List of 
257  Excluded Individuals and Entities. 
258         Section 5. Paragraph (a) of subsection (4) and subsection 
259  (11) of section 408.910, Florida Statutes, are amended to read: 
260         408.910 Florida Health Choices Program.— 
261         (4) ELIGIBILITY AND PARTICIPATION.—Participation in the 
262  program is voluntary and shall be available to employers, 
263  individuals, vendors, and health insurance agents as specified 
264  in this subsection. 
265         (a) Employers eligible to enroll in the program include: 
266         1. Employers that have 1 to 50 employees. 
267         2. Fiscally constrained counties described in s. 218.67. 
268         3. Municipalities having populations of fewer than 50,000 
269  residents. 
270         4. School districts in fiscally constrained counties. 
271         5. State universities and community colleges. 
272         (11) CORPORATION.—There is created the Florida Health 
273  Choices, Inc., which shall be registered, incorporated, 
274  organized, and operated in compliance with part III of chapter 
275  112 and chapters 119, 286, and 617. The purpose of the 
276  corporation is to administer the program created in this section 
277  and to conduct such other business as may further the 
278  administration of the program. 
279         (a)1. The corporation shall be governed by a five-member 
280  15-member board of directors consisting of: 
281         1. Three ex officio, nonvoting members to include: 
282         a. The Secretary of Health Care Administration or a 
283  designee with expertise in health care services. 
284         b. The Secretary of Management Services or a designee with 
285  expertise in state employee benefits. 
286         c. The commissioner of the Office of Insurance Regulation 
287  or a designee with expertise in insurance regulation. 
288         a.2. One member Four members appointed by and serving at 
289  the pleasure of the Governor. 
290         b.3. Two Four members appointed by and serving at the 
291  pleasure of the President of the Senate. 
292         c.4. Two Four members appointed by and serving at the 
293  pleasure of the Speaker of the House of Representatives. 
294         2.5. Board members may not include insurers, health 
295  insurance agents or brokers, health care providers, health 
296  maintenance organizations, prepaid service providers, or any 
297  other entity, affiliate or subsidiary of eligible vendors. 
298         (b)1. Members shall be appointed for terms of up to 4 3 
299  years. In order to establish staggered terms, for the initial 
300  appointments the President of the Senate and the Speaker of the 
301  House of Representatives shall each appoint one member to a 2 
302  year term and one member to a 4-year term. Any member is 
303  eligible for reappointment. A vacancy on the board shall be 
304  filled for the unexpired portion of the term in the same manner 
305  as the original appointment. 
306         2. Beginning July 1, 2011, the members of the board of 
307  directors shall appoint new members to the board of directors, 
308  subject to confirmation by the Senate. 
309         (c) The board shall select a chief executive officer for 
310  the corporation who shall be responsible for the selection of 
311  such other staff as may be authorized by the corporation’s 
312  operating budget as adopted by the board. 
313         (d) Board members are entitled to receive, from funds of 
314  the corporation, reimbursement for per diem and travel expenses 
315  as provided by s. 112.061. No other compensation is authorized. 
316         (e) There is no liability on the part of, and no cause of 
317  action shall arise against, any member of the board or its 
318  employees or agents for any action taken by them in the 
319  performance of their powers and duties under this section. 
320         (f) The board shall develop and adopt bylaws and other 
321  corporate procedures as necessary for the operation of the 
322  corporation and carrying out the purposes of this section. The 
323  bylaws shall: 
324         1. Specify procedures for selection of officers and 
325  qualifications for reappointment, provided that no board member 
326  shall serve more than 9 consecutive years. 
327         2. Require an annual membership meeting that provides an 
328  opportunity for input and interaction with individual 
329  participants in the program. 
330         3. Specify policies and procedures regarding conflicts of 
331  interest, including the provisions of part III of chapter 112, 
332  which prohibit a member from participating in any decision that 
333  would inure to the benefit of the member or the organization 
334  that employs the member. The policies and procedures shall also 
335  require public disclosure of the interest that prevents the 
336  member from participating in a decision on a particular matter. 
337         (g) The corporation may exercise all powers granted to it 
338  under chapter 617 necessary to carry out the purposes of this 
339  section, including, but not limited to, the power to receive and 
340  accept grants, loans, or advances of funds from any public or 
341  private agency and to receive and accept from any source 
342  contributions of money, property, labor, or any other thing of 
343  value to be held, used, and applied for the purposes of this 
344  section. 
345         (h) The corporation may establish technical advisory panels 
346  consisting of interested parties, including consumers, health 
347  care providers, individuals with expertise in insurance 
348  regulation, and insurers. 
349         (i) The corporation shall: 
350         1. Determine eligibility of employers, vendors, 
351  individuals, and agents in accordance with subsection (4). 
352         2. Establish procedures necessary for the operation of the 
353  program, including, but not limited to, procedures for 
354  application, enrollment, risk assessment, risk adjustment, plan 
355  administration, performance monitoring, and consumer education. 
356         3. Arrange for collection of contributions from 
357  participating employers and individuals. 
358         4. Arrange for payment of premiums and other appropriate 
359  disbursements based on the selections of products and services 
360  by the individual participants. 
361         5. Establish criteria for disenrollment of participating 
362  individuals based on failure to pay the individual’s share of 
363  any contribution required to maintain enrollment in selected 
364  products. 
365         6. Establish criteria for exclusion of vendors pursuant to 
366  paragraph (4)(d). 
367         7. Develop and implement a plan for promoting public 
368  awareness of and participation in the program. 
369         8. Secure staff and consultant services necessary to the 
370  operation of the program. 
371         9. Establish policies and procedures regarding 
372  participation in the program for individuals, vendors, health 
373  insurance agents, and employers. 
374         10. Develop a plan, in coordination with the Department of 
375  Revenue, to establish tax credits or refunds for employers that 
376  participate in the program. The corporation shall submit the 
377  plan to the Governor, the President of the Senate, and the 
378  Speaker of the House of Representatives by January 1, 2009. 
379         Section 6. Paragraph (c) of subsection (3) of section 
380  409.907, Florida Statutes, is amended, paragraph (k) is added to 
381  that subsection, and subsection (8), paragraph (b) of subsection 
382  (9), and subsection (10) of that section are amended, to read: 
383         409.907 Medicaid provider agreements.—The agency may make 
384  payments for medical assistance and related services rendered to 
385  Medicaid recipients only to an individual or entity who has a 
386  provider agreement in effect with the agency, who is performing 
387  services or supplying goods in accordance with federal, state, 
388  and local law, and who agrees that no person shall, on the 
389  grounds of handicap, race, color, or national origin, or for any 
390  other reason, be subjected to discrimination under any program 
391  or activity for which the provider receives payment from the 
392  agency. 
393         (3) The provider agreement developed by the agency, in 
394  addition to the requirements specified in subsections (1) and 
395  (2), shall require the provider to: 
396         (c) Retain all medical and Medicaid-related records for a 
397  period of 6 5 years to satisfy all necessary inquiries by the 
398  agency. 
399         (k) Report any change of any principal of the provider, 
400  including any officer, director, agent, managing employee, or 
401  affiliated person, or any partner or shareholder who has an 
402  ownership interest equal to 5 percent or more in the provider. 
403  The provider must report changes to the agency no later than 30 
404  days after the change occurs. Reporting changes in controlling 
405  interests to the agency pursuant to s. 408.810(3) shall serve as 
406  compliance with this paragraph for hospitals licensed under 
407  chapter 395 and nursing homes licensed under chapter 400. 
408         (8)(a) Each provider, or each principal of the provider if 
409  the provider is a corporation, partnership, association, or 
410  other entity, seeking to participate in the Medicaid program 
411  must submit a complete set of his or her fingerprints to the 
412  agency for the purpose of conducting a criminal history record 
413  check. Principals of the provider include any officer, director, 
414  billing agent, managing employee, or affiliated person, or any 
415  partner or shareholder who has an ownership interest equal to 5 
416  percent or more in the provider. However, for hospitals licensed 
417  under chapter 395 and nursing homes licensed under chapter 400, 
418  principals of the provider are those who meet the definition of 
419  a controlling interest in s. 408.803(7). A director of a not 
420  for-profit corporation or organization is not a principal for 
421  purposes of a background investigation as required by this 
422  section if the director: serves solely in a voluntary capacity 
423  for the corporation or organization, does not regularly take 
424  part in the day-to-day operational decisions of the corporation 
425  or organization, receives no remuneration from the not-for 
426  profit corporation or organization for his or her service on the 
427  board of directors, has no financial interest in the not-for 
428  profit corporation or organization, and has no family members 
429  with a financial interest in the not-for-profit corporation or 
430  organization; and if the director submits an affidavit, under 
431  penalty of perjury, to this effect to the agency and the not 
432  for-profit corporation or organization submits an affidavit, 
433  under penalty of perjury, to this effect to the agency as part 
434  of the corporation’s or organization’s Medicaid provider 
435  agreement application. Notwithstanding the above, the agency may 
436  require a background check for any person reasonably suspected 
437  by the agency to have been convicted of a crime. This subsection 
438  does shall not apply to: 
439         1. A hospital licensed under chapter 395; 
440         2. A nursing home licensed under chapter 400; 
441         3. A hospice licensed under chapter 400; 
442         4. An assisted living facility licensed under chapter 429; 
443         1.5. A unit of local government, except that requirements 
444  of this subsection apply to nongovernmental providers and 
445  entities when contracting with the local government to provide 
446  Medicaid services. The actual cost of the state and national 
447  criminal history record checks must be borne by the 
448  nongovernmental provider or entity; or 
449         2.6. Any business that derives more than 50 percent of its 
450  revenue from the sale of goods to the final consumer, and the 
451  business or its controlling parent either is required to file a 
452  form 10-K or other similar statement with the Securities and 
453  Exchange Commission or has a net worth of $50 million or more. 
454         (b) Background screening shall be conducted in accordance 
455  with chapter 435 and s. 408.809. The agency shall submit the 
456  fingerprints to the Department of Law Enforcement. The 
457  department shall conduct a state criminal-background 
458  investigation and forward the fingerprints to the Federal Bureau 
459  of Investigation for a national criminal-history record check. 
460  The cost of the state and national criminal record check shall 
461  be borne by the provider. 
462         (c) The agency may permit a provider to participate in the 
463  Medicaid program pending the results of the criminal record 
464  check. However, such permission is fully revocable if the record 
465  check reveals any crime-related history as provided in 
466  subsection (10). 
467         (c)(d) Proof of compliance with the requirements of level 2 
468  screening under s. 435.04 conducted within 12 months prior to 
469  the date that the Medicaid provider application is submitted to 
470  the agency shall fulfill the requirements of this subsection. 
471  Proof of compliance with the requirements of level 1 screening 
472  under s. 435.03 conducted within 12 months prior to the date 
473  that the Medicaid provider application is submitted to the 
474  agency shall meet the requirement that the Department of Law 
475  Enforcement conduct a state criminal history record check. 
476         (9) Upon receipt of a completed, signed, and dated 
477  application, and completion of any necessary background 
478  investigation and criminal history record check, the agency must 
479  either: 
480         (b) Deny the application if the agency finds that it is in 
481  the best interest of the Medicaid program to do so. The agency 
482  may consider any the factors listed in subsection (10), as well 
483  as any other factor that could affect the effective and 
484  efficient administration of the program, including, but not 
485  limited to, the applicant’s demonstrated ability to provide 
486  services, conduct business, and operate a financially viable 
487  concern; the current availability of medical care, services, or 
488  supplies to recipients, taking into account geographic location 
489  and reasonable travel time; the number of providers of the same 
490  type already enrolled in the same geographic area; and the 
491  credentials, experience, success, and patient outcomes of the 
492  provider for the services that it is making application to 
493  provide in the Medicaid program. The agency shall deny the 
494  application if the agency finds that a provider; any officer, 
495  director, agent, managing employee, or affiliated person; or any 
496  principal, partner, or shareholder having an ownership interest 
497  equal to 5 percent or greater in the provider if the provider is 
498  a corporation, partnership, or other business entity, has failed 
499  to pay all outstanding fines or overpayments assessed by final 
500  order of the agency or final order of the Centers for Medicare 
501  and Medicaid Services, not subject to further appeal, unless the 
502  provider agrees to a repayment plan that includes withholding 
503  Medicaid reimbursement until the amount due is paid in full. 
504         (10) The agency shall deny the application if may consider 
505  whether the provider, or any officer, director, agent, managing 
506  employee, or affiliated person, or any principal, partner, or 
507  shareholder having an ownership interest equal to 5 percent or 
508  greater in the provider if the provider is a corporation, 
509  partnership, or other business entity, has committed an offense 
510  listed in s. 409.913(13), and may deny the application if one of 
511  these persons has: 
512         (a) Made a false representation or omission of any material 
513  fact in making the application, including the submission of an 
514  application that conceals the controlling or ownership interest 
515  of any officer, director, agent, managing employee, affiliated 
516  person, or principal, partner, or shareholder who may not be 
517  eligible to participate; 
518         (b) Been or is currently excluded, suspended, terminated 
519  from, or has involuntarily withdrawn from participation in, 
520  Florida’s Medicaid program or any other state’s Medicaid 
521  program, or from participation in any other governmental or 
522  private health care or health insurance program; 
523         (c) Been convicted of a criminal offense relating to the 
524  delivery of any goods or services under Medicaid or Medicare or 
525  any other public or private health care or health insurance 
526  program including the performance of management or 
527  administrative services relating to the delivery of goods or 
528  services under any such program; 
529         (d) Been convicted under federal or state law of a criminal 
530  offense related to the neglect or abuse of a patient in 
531  connection with the delivery of any health care goods or 
532  services; 
533         (c)(e) Been convicted under federal or state law of a 
534  criminal offense relating to the unlawful manufacture, 
535  distribution, prescription, or dispensing of a controlled 
536  substance; 
537         (d)(f) Been convicted of any criminal offense relating to 
538  fraud, theft, embezzlement, breach of fiduciary responsibility, 
539  or other financial misconduct; 
540         (e)(g) Been convicted under federal or state law of a crime 
541  punishable by imprisonment of a year or more which involves 
542  moral turpitude; 
543         (f)(h) Been convicted in connection with the interference 
544  or obstruction of any investigation into any criminal offense 
545  listed in this subsection; 
546         (g)(i) Been found to have violated federal or state laws, 
547  rules, or regulations governing Florida’s Medicaid program or 
548  any other state’s Medicaid program, the Medicare program, or any 
549  other publicly funded federal or state health care or health 
550  insurance program, and been sanctioned accordingly; 
551         (h)(j) Been previously found by a licensing, certifying, or 
552  professional standards board or agency to have violated the 
553  standards or conditions relating to licensure or certification 
554  or the quality of services provided; or 
555         (i)(k) Failed to pay any fine or overpayment properly 
556  assessed under the Medicaid program in which no appeal is 
557  pending or after resolution of the proceeding by stipulation or 
558  agreement, unless the agency has issued a specific letter of 
559  forgiveness or has approved a repayment schedule to which the 
560  provider agrees to adhere. 
561 
562  If the agency determines a provider did not participate or 
563  acquiesce in an offense specified in s. 409.913(13), the agency 
564  is not required to deny the provider application. 
565         Section 7. Subsections (10), (32), and (48) of section 
566  409.912, Florida Statutes, are amended to read: 
567         409.912 Cost-effective purchasing of health care.—The 
568  agency shall purchase goods and services for Medicaid recipients 
569  in the most cost-effective manner consistent with the delivery 
570  of quality medical care. To ensure that medical services are 
571  effectively utilized, the agency may, in any case, require a 
572  confirmation or second physician’s opinion of the correct 
573  diagnosis for purposes of authorizing future services under the 
574  Medicaid program. This section does not restrict access to 
575  emergency services or poststabilization care services as defined 
576  in 42 C.F.R. part 438.114. Such confirmation or second opinion 
577  shall be rendered in a manner approved by the agency. The agency 
578  shall maximize the use of prepaid per capita and prepaid 
579  aggregate fixed-sum basis services when appropriate and other 
580  alternative service delivery and reimbursement methodologies, 
581  including competitive bidding pursuant to s. 287.057, designed 
582  to facilitate the cost-effective purchase of a case-managed 
583  continuum of care. The agency shall also require providers to 
584  minimize the exposure of recipients to the need for acute 
585  inpatient, custodial, and other institutional care and the 
586  inappropriate or unnecessary use of high-cost services. The 
587  agency shall contract with a vendor to monitor and evaluate the 
588  clinical practice patterns of providers in order to identify 
589  trends that are outside the normal practice patterns of a 
590  provider’s professional peers or the national guidelines of a 
591  provider’s professional association. The vendor must be able to 
592  provide information and counseling to a provider whose practice 
593  patterns are outside the norms, in consultation with the agency, 
594  to improve patient care and reduce inappropriate utilization. 
595  The agency may mandate prior authorization, drug therapy 
596  management, or disease management participation for certain 
597  populations of Medicaid beneficiaries, certain drug classes, or 
598  particular drugs to prevent fraud, abuse, overuse, and possible 
599  dangerous drug interactions. The Pharmaceutical and Therapeutics 
600  Committee shall make recommendations to the agency on drugs for 
601  which prior authorization is required. The agency shall inform 
602  the Pharmaceutical and Therapeutics Committee of its decisions 
603  regarding drugs subject to prior authorization. The agency is 
604  authorized to limit the entities it contracts with or enrolls as 
605  Medicaid providers by developing a provider network through 
606  provider credentialing. The agency may competitively bid single 
607  source-provider contracts if procurement of goods or services 
608  results in demonstrated cost savings to the state without 
609  limiting access to care. The agency may limit its network based 
610  on the assessment of beneficiary access to care, provider 
611  availability, provider quality standards, time and distance 
612  standards for access to care, the cultural competence of the 
613  provider network, demographic characteristics of Medicaid 
614  beneficiaries, practice and provider-to-beneficiary standards, 
615  appointment wait times, beneficiary use of services, provider 
616  turnover, provider profiling, provider licensure history, 
617  previous program integrity investigations and findings, peer 
618  review, provider Medicaid policy and billing compliance records, 
619  clinical and medical record audits, and other factors. Providers 
620  shall not be entitled to enrollment in the Medicaid provider 
621  network. The agency shall determine instances in which allowing 
622  Medicaid beneficiaries to purchase durable medical equipment and 
623  other goods is less expensive to the Medicaid program than long 
624  term rental of the equipment or goods. The agency may establish 
625  rules to facilitate purchases in lieu of long-term rentals in 
626  order to protect against fraud and abuse in the Medicaid program 
627  as defined in s. 409.913. The agency may seek federal waivers 
628  necessary to administer these policies. 
629         (10) The agency shall not contract on a prepaid or fixed 
630  sum basis for Medicaid services with an entity which knows or 
631  reasonably should know that any principal, officer, director, 
632  agent, managing employee, or owner of stock or beneficial 
633  interest in excess of 5 percent common or preferred stock, or 
634  the entity itself, has been found guilty of, regardless of 
635  adjudication, or entered a plea of nolo contendere, or guilty, 
636  to: 
637         (a) An offense listed in s. 408.809, s. 409.913(13), or s. 
638  435.04 Fraud; 
639         (b) Violation of federal or state antitrust statutes, 
640  including those proscribing price fixing between competitors and 
641  the allocation of customers among competitors; 
642         (c) Commission of a felony involving embezzlement, theft, 
643  forgery, income tax evasion, bribery, falsification or 
644  destruction of records, making false statements, receiving 
645  stolen property, making false claims, or obstruction of justice; 
646  or 
647         (d) Any crime in any jurisdiction which directly relates to 
648  the provision of health services on a prepaid or fixed-sum 
649  basis. 
650         (32) Each managed care plan that is under contract with the 
651  agency to provide health care services to Medicaid recipients 
652  shall annually conduct a background check with the Florida 
653  Department of Law Enforcement of all persons with ownership 
654  interest of 5 percent or more or executive management 
655  responsibility for the managed care plan and shall submit to the 
656  agency information concerning any such person who has been found 
657  guilty of, regardless of adjudication, or has entered a plea of 
658  nolo contendere or guilty to, any of the offenses listed in s. 
659  408.809, s. 409.913(13), or s. 435.04 s. 435.03. 
660         (48)(a) A provider is not entitled to enrollment in the 
661  Medicaid provider network. The agency may implement a Medicaid 
662  fee-for-service provider network controls, including, but not 
663  limited to, competitive procurement and provider credentialing. 
664  If a credentialing process is used, the agency may limit its 
665  provider network based upon the following considerations: 
666  beneficiary access to care, provider availability, provider 
667  quality standards and quality assurance processes, cultural 
668  competency, demographic characteristics of beneficiaries, 
669  practice standards, service wait times, provider turnover, 
670  provider licensure and accreditation history, program integrity 
671  history, peer review, Medicaid policy and billing compliance 
672  records, clinical and medical record audit findings, and such 
673  other areas that are considered necessary by the agency to 
674  ensure the integrity of the program. 
675         (b) The agency shall limit its network of durable medical 
676  equipment and medical supply providers. For dates of service 
677  after January 1, 2009, the agency shall limit payment for 
678  durable medical equipment and supplies to providers that meet 
679  all the requirements of this paragraph. 
680         1. Providers must be accredited by a Centers for Medicare 
681  and Medicaid Services deemed accreditation organization for 
682  suppliers of durable medical equipment, prosthetics, orthotics, 
683  and supplies. The provider must maintain accreditation and is 
684  subject to unannounced reviews by the accrediting organization. 
685         2. Providers must provide the services or supplies directly 
686  to the Medicaid recipient or caregiver at the provider location 
687  or recipient’s residence or send the supplies directly to the 
688  recipient’s residence with receipt of mailed delivery. 
689  Subcontracting or consignment of the service or supply to a 
690  third party is prohibited. 
691         3. Notwithstanding subparagraph 2., a durable medical 
692  equipment provider may store nebulizers at a physician’s office 
693  for the purpose of having the physician’s staff issue the 
694  equipment if it meets all of the following conditions: 
695         a. The physician must document the medical necessity and 
696  need to prevent further deterioration of the patient’s 
697  respiratory status by the timely delivery of the nebulizer in 
698  the physician’s office. 
699         b. The durable medical equipment provider must have written 
700  documentation of the competency and training by a Florida 
701  licensed registered respiratory therapist of any durable medical 
702  equipment staff who participate in the training of physician 
703  office staff for the use of nebulizers, including cleaning, 
704  warranty, and special needs of patients. 
705         c. The physician’s office must have documented the training 
706  and competency of any staff member who initiates the delivery of 
707  nebulizers to patients. The durable medical equipment provider 
708  must maintain copies of all physician office training. 
709         d. The physician’s office must maintain inventory records 
710  of stored nebulizers, including documentation of the durable 
711  medical equipment provider source. 
712         e. A physician contracted with a Medicaid durable medical 
713  equipment provider may not have a financial relationship with 
714  that provider or receive any financial gain from the delivery of 
715  nebulizers to patients. 
716         4. Providers must have a physical business location and a 
717  functional landline business phone. The location must be within 
718  the state or not more than 50 miles from the Florida state line. 
719  The agency may make exceptions for providers of durable medical 
720  equipment or supplies not otherwise available from other 
721  enrolled providers located within the state. 
722         5. Physical business locations must be clearly identified 
723  as a business that furnishes durable medical equipment or 
724  medical supplies by signage that can be read from 20 feet away. 
725  The location must be readily accessible to the public during 
726  normal, posted business hours and must operate no less than 5 
727  hours per day and no less than 5 days per week, with the 
728  exception of scheduled and posted holidays. The location may not 
729  be located within or at the same numbered street address as 
730  another enrolled Medicaid durable medical equipment or medical 
731  supply provider or as an enrolled Medicaid pharmacy that is also 
732  enrolled as a durable medical equipment provider. A licensed 
733  orthotist or prosthetist that provides only orthotic or 
734  prosthetic devices as a Medicaid durable medical equipment 
735  provider is exempt from the provisions in this paragraph. 
736         6. Providers must maintain a stock of durable medical 
737  equipment and medical supplies on site that is readily available 
738  to meet the needs of the durable medical equipment business 
739  location’s customers. 
740         7. Providers must provide a surety bond of $50,000 for each 
741  provider location, up to a maximum of 5 bonds statewide or an 
742  aggregate bond of $250,000 statewide, as identified by Federal 
743  Employer Identification Number. Providers who post a statewide 
744  or an aggregate bond must identify all of their locations in any 
745  Medicaid durable medical equipment and medical supply provider 
746  enrollment application or bond renewal. Each provider location’s 
747  surety bond must be renewed annually and the provider must 
748  submit proof of renewal even if the original bond is a 
749  continuous bond. A licensed orthotist or prosthetist that 
750  provides only orthotic or prosthetic devices as a Medicaid 
751  durable medical equipment provider is exempt from the provisions 
752  in this paragraph. 
753         8. Providers must obtain a level 2 background screening, in 
754  accordance with chapter 435 and s. 408.809 as provided under s. 
755  435.04, for each provider employee in direct contact with or 
756  providing direct services to recipients of durable medical 
757  equipment and medical supplies in their homes. This requirement 
758  includes, but is not limited to, repair and service technicians, 
759  fitters, and delivery staff. The provider shall pay for the cost 
760  of the background screening. 
761         9. The following providers are exempt from the requirements 
762  of subparagraphs 1. and 7.: 
763         a. Durable medical equipment providers owned and operated 
764  by a government entity. 
765         b. Durable medical equipment providers that are operating 
766  within a pharmacy that is currently enrolled as a Medicaid 
767  pharmacy provider. 
768         c. Active, Medicaid-enrolled orthopedic physician groups, 
769  primarily owned by physicians, which provide only orthotic and 
770  prosthetic devices. 
771         Section 8. Subsection (13) of section 409.9122, Florida 
772  Statutes, is repealed. 
773         Section 9. Section 409.913, Florida Statutes, is amended to 
774  read: 
775         409.913 Oversight of the integrity of the Medicaid 
776  program.—The agency shall operate a program to oversee the 
777  activities of Florida Medicaid recipients, and providers and 
778  their representatives, to ensure that fraudulent and abusive 
779  behavior and neglect of recipients occur to the minimum extent 
780  possible, and to recover overpayments and impose sanctions as 
781  appropriate. Beginning January 1, 2003, and each year 
782  thereafter, the agency and the Medicaid Fraud Control Unit of 
783  the Department of Legal Affairs shall submit a joint report to 
784  the Legislature documenting the effectiveness of the state’s 
785  efforts to control Medicaid fraud and abuse and to recover 
786  Medicaid overpayments during the previous fiscal year. The 
787  report must describe the number of cases opened and investigated 
788  each year; the sources of the cases opened; the disposition of 
789  the cases closed each year; the amount of overpayments alleged 
790  in preliminary and final audit letters; the number and amount of 
791  fines or penalties imposed; any reductions in overpayment 
792  amounts negotiated in settlement agreements or by other means; 
793  the amount of final agency determinations of overpayments; the 
794  amount deducted from federal claiming as a result of 
795  overpayments; the amount of overpayments recovered each year; 
796  the amount of cost of investigation recovered each year; the 
797  average length of time to collect from the time the case was 
798  opened until the overpayment is paid in full; the amount 
799  determined as uncollectible and the portion of the uncollectible 
800  amount subsequently reclaimed from the Federal Government; the 
801  number of providers, by type, that are terminated from 
802  participation in the Medicaid program as a result of fraud and 
803  abuse; and all costs associated with discovering and prosecuting 
804  cases of Medicaid overpayments and making recoveries in such 
805  cases. The report must also document actions taken to prevent 
806  overpayments and the number of providers prevented from 
807  enrolling in or reenrolling in the Medicaid program as a result 
808  of documented Medicaid fraud and abuse and must include policy 
809  recommendations necessary to prevent or recover overpayments and 
810  changes necessary to prevent and detect Medicaid fraud. All 
811  policy recommendations in the report must include a detailed 
812  fiscal analysis, including, but not limited to, implementation 
813  costs, estimated savings to the Medicaid program, and the return 
814  on investment. The agency must submit the policy recommendations 
815  and fiscal analyses in the report to the appropriate estimating 
816  conference, pursuant to s. 216.137, by February 15 of each year. 
817  The agency and the Medicaid Fraud Control Unit of the Department 
818  of Legal Affairs each must include detailed unit-specific 
819  performance standards, benchmarks, and metrics in the report, 
820  including projected cost savings to the state Medicaid program 
821  during the following fiscal year. 
822         (1) For the purposes of this section, the term: 
823         (a) “Abuse” means: 
824         1. Provider practices that are inconsistent with generally 
825  accepted business or medical practices and that result in an 
826  unnecessary cost to the Medicaid program or in reimbursement for 
827  goods or services that are not medically necessary or that fail 
828  to meet professionally recognized standards for health care. 
829         2. Recipient practices that result in unnecessary cost to 
830  the Medicaid program. 
831         (b) “Complaint” means an allegation that fraud, abuse, or 
832  an overpayment has occurred. 
833         (c) “Fraud” means an intentional deception or 
834  misrepresentation made by a person with the knowledge that the 
835  deception results in unauthorized benefit to herself or himself 
836  or another person. The term includes any act that constitutes 
837  fraud under applicable federal or state law. 
838         (d) “Medical necessity” or “medically necessary” means any 
839  goods or services necessary to palliate the effects of a 
840  terminal condition, or to prevent, diagnose, correct, cure, 
841  alleviate, or preclude deterioration of a condition that 
842  threatens life, causes pain or suffering, or results in illness 
843  or infirmity, which goods or services are provided in accordance 
844  with generally accepted standards of medical practice. For 
845  purposes of determining Medicaid reimbursement, the agency is 
846  the final arbiter of medical necessity. Determinations of 
847  medical necessity must be made by a licensed physician employed 
848  by or under contract with the agency and must be based upon 
849  information available at the time the goods or services are 
850  provided. 
851         (e) “Overpayment” includes any amount that is not 
852  authorized to be paid by the Medicaid program whether paid as a 
853  result of inaccurate or improper cost reporting, improper 
854  claiming, unacceptable practices, fraud, abuse, or mistake. 
855         (f) “Person” means any natural person, corporation, 
856  partnership, association, clinic, group, or other entity, 
857  whether or not such person is enrolled in the Medicaid program 
858  or is a provider of health care. 
859         (2) The agency shall conduct, or cause to be conducted by 
860  contract or otherwise, reviews, investigations, analyses, 
861  audits, or any combination thereof, to determine possible fraud, 
862  abuse, overpayment, or recipient neglect in the Medicaid program 
863  and shall report the findings of any overpayments in audit 
864  reports as appropriate. At least 5 percent of all audits shall 
865  be conducted on a random basis. As part of its ongoing fraud 
866  detection activities, the agency shall identify and monitor, by 
867  contract or otherwise, patterns of overutilization of Medicaid 
868  services based on state averages. The agency shall track 
869  Medicaid provider prescription and billing patterns and evaluate 
870  them against Medicaid medical necessity criteria and coverage 
871  and limitation guidelines adopted by rule. Medical necessity 
872  determination requires that service be consistent with symptoms 
873  or confirmed diagnosis of illness or injury under treatment and 
874  not in excess of the patient’s needs. The agency shall conduct 
875  reviews of provider exceptions to peer group norms and shall, 
876  using statistical methodologies, provider profiling, and 
877  analysis of billing patterns, detect and investigate abnormal or 
878  unusual increases in billing or payment of claims for Medicaid 
879  services and medically unnecessary provision of services. 
880         (3) The agency may conduct, or may contract for, prepayment 
881  review of provider claims to ensure cost-effective purchasing; 
882  to ensure that billing by a provider to the agency is in 
883  accordance with applicable provisions of all Medicaid rules, 
884  regulations, handbooks, and policies and in accordance with 
885  federal, state, and local law; and to ensure that appropriate 
886  care is rendered to Medicaid recipients. Such prepayment reviews 
887  may be conducted as determined appropriate by the agency, 
888  without any suspicion or allegation of fraud, abuse, or neglect, 
889  and may last for up to 1 year. Unless the agency has reliable 
890  evidence of fraud, misrepresentation, abuse, or neglect, claims 
891  shall be adjudicated for denial or payment within 90 days after 
892  receipt of complete documentation by the agency for review. If 
893  there is reliable evidence of fraud, misrepresentation, abuse, 
894  or neglect, claims shall be adjudicated for denial of payment 
895  within 180 days after receipt of complete documentation by the 
896  agency for review. 
897         (4) Any suspected criminal violation identified by the 
898  agency must be referred to the Medicaid Fraud Control Unit of 
899  the Office of the Attorney General for investigation. The agency 
900  and the Attorney General shall enter into a memorandum of 
901  understanding, which must include, but need not be limited to, a 
902  protocol for regularly sharing information and coordinating 
903  casework. The protocol must establish a procedure for the 
904  referral by the agency of cases involving suspected Medicaid 
905  fraud to the Medicaid Fraud Control Unit for investigation, and 
906  the return to the agency of those cases where investigation 
907  determines that administrative action by the agency is 
908  appropriate. Offices of the Medicaid program integrity program 
909  and the Medicaid Fraud Control Unit of the Department of Legal 
910  Affairs, shall, to the extent possible, be collocated. The 
911  agency and the Department of Legal Affairs shall periodically 
912  conduct joint training and other joint activities designed to 
913  increase communication and coordination in recovering 
914  overpayments. 
915         (5) A Medicaid provider is subject to having goods and 
916  services that are paid for by the Medicaid program reviewed by 
917  an appropriate peer-review organization designated by the 
918  agency. The written findings of the applicable peer-review 
919  organization are admissible in any court or administrative 
920  proceeding as evidence of medical necessity or the lack thereof. 
921         (6) Any notice required to be given to a provider under 
922  this section is presumed to be sufficient notice if sent to the 
923  address last shown on the provider enrollment file. It is the 
924  responsibility of the provider to furnish and keep the agency 
925  informed of the provider’s current address. United States Postal 
926  Service proof of mailing or certified or registered mailing of 
927  such notice to the provider at the address shown on the provider 
928  enrollment file constitutes sufficient proof of notice. Any 
929  notice required to be given to the agency by this section must 
930  be sent to the agency at an address designated by rule. 
931         (7) When presenting a claim for payment under the Medicaid 
932  program, a provider has an affirmative duty to supervise the 
933  provision of, and be responsible for, goods and services claimed 
934  to have been provided, to supervise and be responsible for 
935  preparation and submission of the claim, and to present a claim 
936  that is true and accurate and that is for goods and services 
937  that: 
938         (a) Have actually been furnished to the recipient by the 
939  provider prior to submitting the claim. 
940         (b) Are Medicaid-covered goods or services that are 
941  medically necessary. 
942         (c) Are of a quality comparable to those furnished to the 
943  general public by the provider’s peers. 
944         (d) Have not been billed in whole or in part to a recipient 
945  or a recipient’s responsible party, except for such copayments, 
946  coinsurance, or deductibles as are authorized by the agency. 
947         (e) Are provided in accord with applicable provisions of 
948  all Medicaid rules, regulations, handbooks, and policies and in 
949  accordance with federal, state, and local law. 
950         (f) Are documented by records made at the time the goods or 
951  services were provided, demonstrating the medical necessity for 
952  the goods or services rendered. Medicaid goods or services are 
953  excessive or not medically necessary unless both the medical 
954  basis and the specific need for them are fully and properly 
955  documented in the recipient’s medical record. 
956 
957  The agency shall deny payment or require repayment for goods or 
958  services that are not presented as required in this subsection. 
959         (8) The agency shall not reimburse any person or entity for 
960  any prescription for medications, medical supplies, or medical 
961  services if the prescription was written by a physician or other 
962  prescribing practitioner who is not enrolled in the Medicaid 
963  program. This section does not apply: 
964         (a) In instances involving bona fide emergency medical 
965  conditions as determined by the agency; 
966         (b) To a provider of medical services to a patient in a 
967  hospital emergency department, hospital inpatient or outpatient 
968  setting, or nursing home; 
969         (c) To bona fide pro bono services by preapproved non 
970  Medicaid providers as determined by the agency; 
971         (d) To prescribing physicians who are board-certified 
972  specialists treating Medicaid recipients referred for treatment 
973  by a treating physician who is enrolled in the Medicaid program; 
974         (e) To prescriptions written for dually eligible Medicare 
975  beneficiaries by an authorized Medicare provider who is not 
976  enrolled in the Medicaid program; 
977         (f) To other physicians who are not enrolled in the 
978  Medicaid program but who provide a medically necessary service 
979  or prescription not otherwise reasonably available from a 
980  Medicaid-enrolled physician; or 
981         (9) A Medicaid provider shall retain medical, professional, 
982  financial, and business records pertaining to services and goods 
983  furnished to a Medicaid recipient and billed to Medicaid for a 
984  period of 6 5 years after the date of furnishing such services 
985  or goods. The agency may investigate, review, or analyze such 
986  records, which must be made available during normal business 
987  hours. However, 24-hour notice must be provided if patient 
988  treatment would be disrupted. The provider is responsible for 
989  furnishing to the agency, and keeping the agency informed of the 
990  location of, the provider’s Medicaid-related records. The 
991  authority of the agency to obtain Medicaid-related records from 
992  a provider is neither curtailed nor limited during a period of 
993  litigation between the agency and the provider. 
994         (10) Payments for the services of billing agents or persons 
995  participating in the preparation of a Medicaid claim shall not 
996  be based on amounts for which they bill nor based on the amount 
997  a provider receives from the Medicaid program. 
998         (11) The agency shall deny payment or require repayment for 
999  inappropriate, medically unnecessary, or excessive goods or 
1000  services from the person furnishing them, the person under whose 
1001  supervision they were furnished, or the person causing them to 
1002  be furnished. 
1003         (12) The complaint and all information obtained pursuant to 
1004  an investigation of a Medicaid provider, or the authorized 
1005  representative or agent of a provider, relating to an allegation 
1006  of fraud, abuse, or neglect are confidential and exempt from the 
1007  provisions of s. 119.07(1): 
1008         (a) Until the agency takes final agency action with respect 
1009  to the provider and requires repayment of any overpayment, or 
1010  imposes an administrative sanction; 
1011         (b) Until the Attorney General refers the case for criminal 
1012  prosecution; 
1013         (c) Until 10 days after the complaint is determined without 
1014  merit; or 
1015         (d) At all times if the complaint or information is 
1016  otherwise protected by law. 
1017         (13) The agency shall immediately terminate participation 
1018  of a Medicaid provider in the Medicaid program and may seek 
1019  civil remedies or impose other administrative sanctions against 
1020  a Medicaid provider, if the provider or any principal, officer, 
1021  director, agent, managing employee, or affiliated person of the 
1022  provider, or any partner or shareholder having an ownership 
1023  interest in the provider equal to 5 percent or greater, has 
1024  been: 
1025         (a) Convicted of a criminal offense related to the delivery 
1026  of any health care goods or services, including the performance 
1027  of management or administrative functions relating to the 
1028  delivery of health care goods or services; 
1029         (b) Convicted of a criminal offense under federal law or 
1030  the law of any state relating to the practice of the provider’s 
1031  profession; or 
1032         (c) Found by a court of competent jurisdiction to have 
1033  neglected or physically abused a patient in connection with the 
1034  delivery of health care goods or services. 
1035 
1036  If the agency determines a provider did not participate or 
1037  acquiesce in an offense specified in paragraph (a), paragraph 
1038  (b), or paragraph (c), termination will not be imposed. If the 
1039  agency effects a termination under this subsection, the agency 
1040  shall issue an immediate termination final order as provided in 
1041  subsection (16) pursuant to s. 120.569(2)(n). 
1042         (14) If the provider has been suspended or terminated from 
1043  participation in the Medicaid program or the Medicare program by 
1044  the Federal Government or any state, the agency must immediately 
1045  suspend or terminate, as appropriate, the provider’s 
1046  participation in this state’s Medicaid program for a period no 
1047  less than that imposed by the Federal Government or any other 
1048  state, and may not enroll such provider in this state’s Medicaid 
1049  program while such foreign suspension or termination remains in 
1050  effect. The agency shall also immediately suspend or terminate, 
1051  as appropriate, a provider’s participation in this state’s 
1052  Medicaid program if the provider participated or acquiesced in 
1053  any action for which any principal, officer, director, agent, 
1054  managing employee, or affiliated person of the provider, or any 
1055  partner or shareholder having an ownership interest in the 
1056  provider equal to 5 percent or greater, was suspended or 
1057  terminated from participating in the Medicaid program or the 
1058  Medicare program by the Federal Government or any state. This 
1059  sanction is in addition to all other remedies provided by law. 
1060  If the agency suspends or terminates a provider’s participation 
1061  in the state’s Medicaid program under this subsection, the 
1062  agency shall issue an immediate suspension or immediate 
1063  termination order as provided in subsection (16). 
1064         (15) The agency shall seek a remedy provided by law, 
1065  including, but not limited to, any remedy provided in 
1066  subsections (13) and (16) and s. 812.035, if: 
1067         (a) The provider’s license has not been renewed, or has 
1068  been revoked, suspended, or terminated, for cause, by the 
1069  licensing agency of any state; 
1070         (b) The provider has failed to make available or has 
1071  refused access to Medicaid-related records to an auditor, 
1072  investigator, or other authorized employee or agent of the 
1073  agency, the Attorney General, a state attorney, or the Federal 
1074  Government; 
1075         (c) The provider has not furnished or has failed to make 
1076  available such Medicaid-related records as the agency has found 
1077  necessary to determine whether Medicaid payments are or were due 
1078  and the amounts thereof; 
1079         (d) The provider has failed to maintain medical records 
1080  made at the time of service, or prior to service if prior 
1081  authorization is required, demonstrating the necessity and 
1082  appropriateness of the goods or services rendered; 
1083         (e) The provider is not in compliance with provisions of 
1084  Medicaid provider publications that have been adopted by 
1085  reference as rules in the Florida Administrative Code; with 
1086  provisions of state or federal laws, rules, or regulations; with 
1087  provisions of the provider agreement between the agency and the 
1088  provider; or with certifications found on claim forms or on 
1089  transmittal forms for electronically submitted claims that are 
1090  submitted by the provider or authorized representative, as such 
1091  provisions apply to the Medicaid program; 
1092         (f) The provider or person who ordered or prescribed the 
1093  care, services, or supplies has furnished, or ordered the 
1094  furnishing of, goods or services to a recipient which are 
1095  inappropriate, unnecessary, excessive, or harmful to the 
1096  recipient or are of inferior quality; 
1097         (g) The provider has demonstrated a pattern of failure to 
1098  provide goods or services that are medically necessary; 
1099         (h) The provider or an authorized representative of the 
1100  provider, or a person who ordered or prescribed the goods or 
1101  services, has submitted or caused to be submitted false or a 
1102  pattern of erroneous Medicaid claims; 
1103         (i) The provider or an authorized representative of the 
1104  provider, or a person who has ordered or prescribed the goods or 
1105  services, has submitted or caused to be submitted a Medicaid 
1106  provider enrollment application, a request for prior 
1107  authorization for Medicaid services, a drug exception request, 
1108  or a Medicaid cost report that contains materially false or 
1109  incorrect information; 
1110         (j) The provider or an authorized representative of the 
1111  provider has collected from or billed a recipient or a 
1112  recipient’s responsible party improperly for amounts that should 
1113  not have been so collected or billed by reason of the provider’s 
1114  billing the Medicaid program for the same service; 
1115         (k) The provider or an authorized representative of the 
1116  provider has included in a cost report costs that are not 
1117  allowable under a Florida Title XIX reimbursement plan, after 
1118  the provider or authorized representative had been advised in an 
1119  audit exit conference or audit report that the costs were not 
1120  allowable; 
1121         (l) The provider is charged by information or indictment 
1122  with fraudulent billing practices or an offense under subsection 
1123  (13). The sanction applied for this reason is limited to 
1124  suspension of the provider’s participation in the Medicaid 
1125  program for the duration of the indictment unless the provider 
1126  is found guilty pursuant to the information or indictment; 
1127         (m) The provider or a person who has ordered or prescribed 
1128  the goods or services is found liable for negligent practice 
1129  resulting in death or injury to the provider’s patient; 
1130         (n) The provider fails to demonstrate that it had available 
1131  during a specific audit or review period sufficient quantities 
1132  of goods, or sufficient time in the case of services, to support 
1133  the provider’s billings to the Medicaid program; 
1134         (o) The provider has failed to comply with the notice and 
1135  reporting requirements of s. 409.907; 
1136         (p) The agency has received reliable information of patient 
1137  abuse or neglect or of any act prohibited by s. 409.920; or 
1138         (q) The provider has failed to comply with an agreed-upon 
1139  repayment schedule. 
1140 
1141  A provider is subject to sanctions for violations of this 
1142  subsection as the result of actions or inactions of the 
1143  provider, or actions or inactions of any principal, officer, 
1144  director, agent, managing employee, or affiliated person of the 
1145  provider, or any partner or shareholder having an ownership 
1146  interest in the provider equal to 5 percent or greater, in which 
1147  the provider participated or acquiesced. If the agency 
1148  immediately suspends or immediately terminates a provider under 
1149  this subsection, the agency shall issue an immediate suspension 
1150  or immediate termination order as provided in subsection (16). 
1151         (16) The agency shall impose any of the following sanctions 
1152  or disincentives on a provider or a person for any of the acts 
1153  described in subsection (15): 
1154         (a) Suspension for a specific period of time of not more 
1155  than 1 year. Suspension shall preclude participation in the 
1156  Medicaid program, which includes any action that results in a 
1157  claim for payment to the Medicaid program as a result of 
1158  furnishing, supervising a person who is furnishing, or causing a 
1159  person to furnish goods or services. 
1160         (b) Termination for a specific period of time of from more 
1161  than 1 year to 20 years. Termination shall preclude 
1162  participation in the Medicaid program, which includes any action 
1163  that results in a claim for payment to the Medicaid program as a 
1164  result of furnishing, supervising a person who is furnishing, or 
1165  causing a person to furnish goods or services. 
1166         (c) Imposition of a fine of up to $5,000 for each 
1167  violation. Each day that an ongoing violation continues, such as 
1168  refusing to furnish Medicaid-related records or refusing access 
1169  to records, is considered, for the purposes of this section, to 
1170  be a separate violation. Each instance of improper billing of a 
1171  Medicaid recipient; each instance of including an unallowable 
1172  cost on a hospital or nursing home Medicaid cost report after 
1173  the provider or authorized representative has been advised in an 
1174  audit exit conference or previous audit report of the cost 
1175  unallowability; each instance of furnishing a Medicaid recipient 
1176  goods or professional services that are inappropriate or of 
1177  inferior quality as determined by competent peer judgment; each 
1178  instance of knowingly submitting a materially false or erroneous 
1179  Medicaid provider enrollment application, request for prior 
1180  authorization for Medicaid services, drug exception request, or 
1181  cost report; each instance of inappropriate prescribing of drugs 
1182  for a Medicaid recipient as determined by competent peer 
1183  judgment; and each false or erroneous Medicaid claim leading to 
1184  an overpayment to a provider is considered, for the purposes of 
1185  this section, to be a separate violation. 
1186         (d) Immediate suspension, if the agency has received 
1187  information of patient abuse or neglect, or of any act 
1188  prohibited by s. 409.920, or any conduct listed in subsection 
1189  (13) or subsection (14). Upon suspension, the agency must issue 
1190  an immediate suspension final order, which shall state that the 
1191  agency has reasonable cause to believe that the provider, 
1192  person, or entity named is engaging in or has engaged in patient 
1193  abuse or neglect, any act prohibited by s. 409.920, or any 
1194  conduct listed in subsection (13) or subsection (14). The order 
1195  shall provide notice of administrative hearing rights under ss. 
1196  120.569 and 120.57 and is effective immediately upon notice to 
1197  the provider, person, or entity under s. 120.569(2)(n). 
1198         (e) Immediate termination, if the agency has received 
1199  information of a conviction based on patient abuse or neglect, 
1200  any act prohibited by s. 409.920, or any conduct listed in 
1201  subsection (13) or subsection (14). Upon termination, the agency 
1202  must issue an immediate termination order, which shall state 
1203  that the agency has reasonable cause to believe that the 
1204  provider, person, or entity named has been convicted of patient 
1205  abuse or neglect, any act prohibited by s. 409.920, or any 
1206  conduct listed in subsection (13) or subsection (14). The 
1207  termination order shall provide notice of administrative hearing 
1208  rights under ss. 120.569 and 120.57 and is effective immediately 
1209  upon notice to the provider, person, or entity. 
1210         (f)(e) A fine, not to exceed $10,000, for a violation of 
1211  paragraph (15)(i). 
1212         (g)(f) Imposition of liens against provider assets, 
1213  including, but not limited to, financial assets and real 
1214  property, not to exceed the amount of fines or recoveries 
1215  sought, upon entry of an order determining that such moneys are 
1216  due or recoverable. 
1217         (h)(g) Prepayment reviews of claims for a specified period 
1218  of time. 
1219         (i)(h) Comprehensive followup reviews of providers every 6 
1220  months to ensure that they are billing Medicaid correctly. 
1221         (j)(i) Corrective-action plans that would remain in effect 
1222  for providers for up to 3 years and that would be monitored by 
1223  the agency every 6 months while in effect. 
1224         (k)(j) Other remedies as permitted by law to effect the 
1225  recovery of a fine or overpayment. 
1226 
1227  The Secretary of Health Care Administration may make a 
1228  determination that imposition of a sanction or disincentive is 
1229  not in the best interest of the Medicaid program, in which case 
1230  a sanction or disincentive shall not be imposed. 
1231         (17) In determining the appropriate administrative sanction 
1232  to be applied, or the duration of any suspension or termination, 
1233  the agency shall consider: 
1234         (a) The seriousness and extent of the violation or 
1235  violations. 
1236         (b) Any prior history of violations by the provider 
1237  relating to the delivery of health care programs which resulted 
1238  in either a criminal conviction or in administrative sanction or 
1239  penalty. 
1240         (c) Evidence of continued violation within the provider’s 
1241  management control of Medicaid statutes, rules, regulations, or 
1242  policies after written notification to the provider of improper 
1243  practice or instance of violation. 
1244         (d) The effect, if any, on the quality of medical care 
1245  provided to Medicaid recipients as a result of the acts of the 
1246  provider. 
1247         (e) Any action by a licensing agency respecting the 
1248  provider in any state in which the provider operates or has 
1249  operated. 
1250         (f) The apparent impact on access by recipients to Medicaid 
1251  services if the provider is suspended or terminated, in the best 
1252  judgment of the agency. 
1253 
1254  The agency shall document the basis for all sanctioning actions 
1255  and recommendations. 
1256         (18) The agency may take action to sanction, suspend, or 
1257  terminate a particular provider working for a group provider, 
1258  and may suspend or terminate Medicaid participation at a 
1259  specific location, rather than or in addition to taking action 
1260  against an entire group. 
1261         (19) The agency shall establish a process for conducting 
1262  followup reviews of a sampling of providers who have a history 
1263  of overpayment under the Medicaid program. This process must 
1264  consider the magnitude of previous fraud or abuse and the 
1265  potential effect of continued fraud or abuse on Medicaid costs. 
1266         (20) In making a determination of overpayment to a 
1267  provider, the agency must use accepted and valid auditing, 
1268  accounting, analytical, statistical, or peer-review methods, or 
1269  combinations thereof. Appropriate statistical methods may 
1270  include, but are not limited to, sampling and extension to the 
1271  population, parametric and nonparametric statistics, tests of 
1272  hypotheses, and other generally accepted statistical methods. 
1273  Appropriate analytical methods may include, but are not limited 
1274  to, reviews to determine variances between the quantities of 
1275  products that a provider had on hand and available to be 
1276  purveyed to Medicaid recipients during the review period and the 
1277  quantities of the same products paid for by the Medicaid program 
1278  for the same period, taking into appropriate consideration sales 
1279  of the same products to non-Medicaid customers during the same 
1280  period. In meeting its burden of proof in any administrative or 
1281  court proceeding, the agency may introduce the results of such 
1282  statistical methods as evidence of overpayment. 
1283         (21) When making a determination that an overpayment has 
1284  occurred, the agency shall prepare and issue an audit report to 
1285  the provider showing the calculation of overpayments. 
1286         (22) The audit report, supported by agency work papers, 
1287  showing an overpayment to a provider constitutes evidence of the 
1288  overpayment. A provider may not present or elicit testimony, 
1289  either on direct examination or cross-examination in any court 
1290  or administrative proceeding, regarding the purchase or 
1291  acquisition by any means of drugs, goods, or supplies; sales or 
1292  divestment by any means of drugs, goods, or supplies; or 
1293  inventory of drugs, goods, or supplies, unless such acquisition, 
1294  sales, divestment, or inventory is documented by written 
1295  invoices, written inventory records, or other competent written 
1296  documentary evidence maintained in the normal course of the 
1297  provider’s business. Notwithstanding the applicable rules of 
1298  discovery, all documentation that will be offered as evidence at 
1299  an administrative hearing on a Medicaid overpayment must be 
1300  exchanged by all parties at least 14 days before the 
1301  administrative hearing or must be excluded from consideration. 
1302         (23)(a) In an audit or investigation of a violation 
1303  committed by a provider which is conducted pursuant to this 
1304  section, the agency is entitled to recover all investigative, 
1305  legal, and expert witness costs if the agency’s findings were 
1306  not contested by the provider or, if contested, the agency 
1307  ultimately prevailed. 
1308         (b) The agency has the burden of documenting the costs, 
1309  which include salaries and employee benefits and out-of-pocket 
1310  expenses. The amount of costs that may be recovered must be 
1311  reasonable in relation to the seriousness of the violation and 
1312  must be set taking into consideration the financial resources, 
1313  earning ability, and needs of the provider, who has the burden 
1314  of demonstrating such factors. 
1315         (c) The provider may pay the costs over a period to be 
1316  determined by the agency if the agency determines that an 
1317  extreme hardship would result to the provider from immediate 
1318  full payment. Any default in payment of costs may be collected 
1319  by any means authorized by law. 
1320         (24) If the agency imposes an administrative sanction 
1321  pursuant to subsection (13), subsection (14), or subsection 
1322  (15), except paragraphs (15)(e) and (o), upon any provider or 
1323  any principal, officer, director, agent, managing employee, or 
1324  affiliated person of the provider who is regulated by another 
1325  state entity, the agency shall notify that other entity of the 
1326  imposition of the sanction within 5 business days. Such 
1327  notification must include the provider’s or person’s name and 
1328  license number and the specific reasons for sanction. 
1329         (25)(a) The agency shall withhold Medicaid payments, in 
1330  whole or in part, to a provider upon receipt of reliable 
1331  evidence that the circumstances giving rise to the need for a 
1332  withholding of payments involve fraud, willful 
1333  misrepresentation, or abuse under the Medicaid program, or a 
1334  crime committed while rendering goods or services to Medicaid 
1335  recipients. If the provider is not paid within 14 days after the 
1336  agency receives evidence it is determined that fraud, willful 
1337  misrepresentation, abuse, or a crime did not occur, interest 
1338  shall accrue at a rate of 10 percent a year the payments 
1339  withheld must be paid to the provider within 14 days after such 
1340  determination with interest at the rate of 10 percent a year. 
1341  Any money withheld in accordance with this paragraph shall be 
1342  placed in a suspended account, readily accessible to the agency, 
1343  so that any payment ultimately due the provider shall be made 
1344  within 14 days. 
1345         (b) The agency shall deny payment, or require repayment, if 
1346  the goods or services were furnished, supervised, or caused to 
1347  be furnished by a person who has been convicted of a crime under 
1348  subsection (13) or who has been suspended or terminated from the 
1349  Medicaid program or Medicare program by the Federal Government 
1350  or any state. 
1351         (c) Overpayments owed to the agency bear interest at the 
1352  rate of 10 percent per year from the date of determination of 
1353  the overpayment by the agency, and payment arrangements for 
1354  overpayments and fines must be made within 35 days after the 
1355  date of the final order at the conclusion of legal proceedings. 
1356  A provider who does not enter into or adhere to an agreed-upon 
1357  repayment schedule may be terminated by the agency for 
1358  nonpayment or partial payment. 
1359         (d) The agency, upon entry of a final agency order, a 
1360  judgment or order of a court of competent jurisdiction, or a 
1361  stipulation or settlement, may collect the moneys owed by all 
1362  means allowable by law, including, but not limited to, notifying 
1363  any fiscal intermediary of Medicare benefits that the state has 
1364  a superior right of payment. Upon receipt of such written 
1365  notification, the Medicare fiscal intermediary shall remit to 
1366  the state the sum claimed. 
1367         (e) The agency may institute amnesty programs to allow 
1368  Medicaid providers the opportunity to voluntarily repay 
1369  overpayments. The agency may adopt rules to administer such 
1370  programs. 
1371         (26) The agency may impose administrative sanctions against 
1372  a Medicaid recipient, or the agency may seek any other remedy 
1373  provided by law, including, but not limited to, the remedies 
1374  provided in s. 812.035, if the agency finds that a recipient has 
1375  engaged in solicitation in violation of s. 409.920 or that the 
1376  recipient has otherwise abused the Medicaid program. 
1377         (27) When the Agency for Health Care Administration has 
1378  made a probable cause determination and alleged that an 
1379  overpayment to a Medicaid provider has occurred, the agency, 
1380  after notice to the provider, shall: 
1381         (a) Withhold, and continue to withhold during the pendency 
1382  of an administrative hearing pursuant to chapter 120, any 
1383  medical assistance reimbursement payments until such time as the 
1384  overpayment is recovered, unless within 30 days after receiving 
1385  notice thereof the provider: 
1386         1. Makes repayment in full; or 
1387         2. Establishes a repayment plan that is satisfactory to the 
1388  Agency for Health Care Administration. 
1389         (b) Withhold, and continue to withhold during the pendency 
1390  of an administrative hearing pursuant to chapter 120, medical 
1391  assistance reimbursement payments if the terms of a repayment 
1392  plan are not adhered to by the provider. 
1393         (28) Venue for all Medicaid program integrity overpayment 
1394  cases shall lie in Leon County, at the discretion of the agency. 
1395         (29) Notwithstanding other provisions of law, the agency 
1396  and the Medicaid Fraud Control Unit of the Department of Legal 
1397  Affairs may review a provider’s Medicaid-related and non 
1398  Medicaid-related records in order to determine the total output 
1399  of a provider’s practice to reconcile quantities of goods or 
1400  services billed to Medicaid with quantities of goods or services 
1401  used in the provider’s total practice. 
1402         (30) The agency shall terminate a provider’s participation 
1403  in the Medicaid program if the provider fails to reimburse an 
1404  overpayment or fine that has been determined by final order, not 
1405  subject to further appeal, within 35 days after the date of the 
1406  final order, unless the provider and the agency have entered 
1407  into a repayment agreement. 
1408         (31) If a provider requests an administrative hearing 
1409  pursuant to chapter 120, such hearing must be conducted within 
1410  90 days following assignment of an administrative law judge, 
1411  absent exceptionally good cause shown as determined by the 
1412  administrative law judge or hearing officer. Upon issuance of a 
1413  final order, the outstanding balance of the amount determined to 
1414  constitute the overpayment or fine shall become due. If a 
1415  provider fails to make payments in full, fails to enter into a 
1416  satisfactory repayment plan, or fails to comply with the terms 
1417  of a repayment plan or settlement agreement, the agency shall 
1418  withhold medical assistance reimbursement payments until the 
1419  amount due is paid in full. 
1420         (32) Duly authorized agents and employees of the agency 
1421  shall have the power to inspect, during normal business hours, 
1422  the records of any pharmacy, wholesale establishment, or 
1423  manufacturer, or any other place in which drugs and medical 
1424  supplies are manufactured, packed, packaged, made, stored, sold, 
1425  or kept for sale, for the purpose of verifying the amount of 
1426  drugs and medical supplies ordered, delivered, or purchased by a 
1427  provider. The agency shall provide at least 2 business days’ 
1428  prior notice of any such inspection. The notice must identify 
1429  the provider whose records will be inspected, and the inspection 
1430  shall include only records specifically related to that 
1431  provider. 
1432         (33) In accordance with federal law, Medicaid recipients 
1433  convicted of a crime pursuant to 42 U.S.C. s. 1320a-7b may be 
1434  limited, restricted, or suspended from Medicaid eligibility for 
1435  a period not to exceed 1 year, as determined by the agency head 
1436  or designee. 
1437         (34) To deter fraud and abuse in the Medicaid program, the 
1438  agency may limit the number of Schedule II and Schedule III 
1439  refill prescription claims submitted from a pharmacy provider. 
1440  The agency shall limit the allowable amount of reimbursement of 
1441  prescription refill claims for Schedule II and Schedule III 
1442  pharmaceuticals if the agency or the Medicaid Fraud Control Unit 
1443  determines that the specific prescription refill was not 
1444  requested by the Medicaid recipient or authorized representative 
1445  for whom the refill claim is submitted or was not prescribed by 
1446  the recipient’s medical provider or physician. Any such refill 
1447  request must be consistent with the original prescription. 
1448         (35) The Office of Program Policy Analysis and Government 
1449  Accountability shall provide a report to the President of the 
1450  Senate and the Speaker of the House of Representatives on a 
1451  biennial basis, beginning January 31, 2006, on the agency’s and 
1452  the Medicaid Fraud Control Unit’s efforts to prevent, detect, 
1453  and deter, as well as recover funds lost to, fraud and abuse in 
1454  the Medicaid program. 
1455         (36) At least three times a year, the agency shall provide 
1456  to each Medicaid recipient or his or her representative an 
1457  explanation of benefits in the form of a letter that is mailed 
1458  to the most recent address of the recipient on the record with 
1459  the Department of Children and Family Services. The explanation 
1460  of benefits must include the patient’s name, the name of the 
1461  health care provider and the address of the location where the 
1462  service was provided, a description of all services billed to 
1463  Medicaid in terminology that should be understood by a 
1464  reasonable person, and information on how to report 
1465  inappropriate or incorrect billing to the agency or other law 
1466  enforcement entities for review or investigation. At least once 
1467  a year, the letter also must include information on how to 
1468  report criminal Medicaid fraud, the Medicaid Fraud Control 
1469  Unit’s toll-free hotline number, and information about the 
1470  rewards available under s. 409.9203. The explanation of benefits 
1471  may not be mailed for Medicaid independent laboratory services 
1472  as described in s. 409.905(7) or for Medicaid certified match 
1473  services as described in ss. 409.9071 and 1011.70. 
1474         (37) The agency shall post on its website a current list of 
1475  each Medicaid provider, including any principal, officer, 
1476  director, agent, managing employee, or affiliated person of the 
1477  provider, or any partner or shareholder having an ownership 
1478  interest in the provider equal to 5 percent or greater, who has 
1479  been terminated for cause from the Medicaid program or 
1480  sanctioned under this section. The list must be searchable by a 
1481  variety of search parameters and provide for the creation of 
1482  formatted lists that may be printed or imported into other 
1483  applications, including spreadsheets. The agency shall update 
1484  the list at least monthly. 
1485         (38) In order to improve the detection of health care 
1486  fraud, use technology to prevent and detect fraud, and maximize 
1487  the electronic exchange of health care fraud information, the 
1488  agency shall: 
1489         (a) Compile, maintain, and publish on its website a 
1490  detailed list of all state and federal databases that contain 
1491  health care fraud information and update the list at least 
1492  biannually; 
1493         (b) Develop a strategic plan to connect all databases that 
1494  contain health care fraud information to facilitate the 
1495  electronic exchange of health information between the agency, 
1496  the Department of Health, the Department of Law Enforcement, and 
1497  the Attorney General’s Office. The plan must include recommended 
1498  standard data formats, fraud identification strategies, and 
1499  specifications for the technical interface between state and 
1500  federal health care fraud databases; 
1501         (c) Monitor innovations in health information technology, 
1502  specifically as it pertains to Medicaid fraud prevention and 
1503  detection; and 
1504         (d) Periodically publish policy briefs that highlight 
1505  available new technology to prevent or detect health care fraud 
1506  and projects implemented by other states, the private sector, or 
1507  the Federal Government which use technology to prevent or detect 
1508  health care fraud. 
1509         Section 10. Subsection (5) is added to section 409.9203, 
1510  Florida Statutes, to read: 
1511         409.9203 Rewards for reporting Medicaid fraud.— 
1512         (5) An employee of the Agency for Health Care 
1513  Administration, the Department of Legal Affairs, the Department 
1514  of Health, or the Department of Law Enforcement whose job 
1515  responsibilities include the prevention, detection, and 
1516  prosecution of Medicaid fraud is not eligible to receive a 
1517  reward under this section. 
1518         Section 11. Subsection (8) is added to section 456.001, 
1519  Florida Statutes, to read: 
1520         456.001 Definitions.—As used in this chapter, the term: 
1521         (8) “Affiliate” or “affiliated person” means any person who 
1522  directly or indirectly manages, controls, or oversees the 
1523  operation of a corporation or other business entity, regardless 
1524  of whether such person is a partner, shareholder, owner, 
1525  officer, director, or agent of the entity. 
1526         Section 12. Paragraph (c) of subsection (1) and subsections 
1527  (2) and (3) of section 456.041, Florida Statutes, are amended to 
1528  read: 
1529         456.041 Practitioner profile; creation.— 
1530         (1) 
1531         (c) Within 30 calendar days after receiving an update of 
1532  information required for the practitioner’s profile, the 
1533  department shall update the practitioner’s profile in accordance 
1534  with the requirements of subsection (8) (7). 
1535         (2) Beginning July 1, 2010, on the profile published under 
1536  subsection (1), the department shall include indicate if the 
1537  information provided under s. 456.039(1)(a)7. or s. 
1538  456.0391(1)(a)7. and indicate if the information is or is not 
1539  corroborated by a criminal history records check conducted 
1540  according to this subsection. The department must include in 
1541  each practitioner’s profile the following statement: “The 
1542  criminal history information, if any exists, may be incomplete. 
1543  Federal criminal history information is not available to the 
1544  public.” The department, or the board having regulatory 
1545  authority over the practitioner acting on behalf of the 
1546  department, shall investigate any information received by the 
1547  department or the board. 
1548         (3) Beginning July 1, 2010, the department shall include in 
1549  each practitioner’s profile any open administrative complaint 
1550  filed with the department against the practitioner in which 
1551  probable cause has been found. The Department of Health shall 
1552  include in each practitioner’s practitioner profile that 
1553  criminal information that directly relates to the practitioner’s 
1554  ability to competently practice his or her profession. The 
1555  department must include in each practitioner’s practitioner 
1556  profile the following statement: “The criminal history 
1557  information, if any exists, may be incomplete; federal criminal 
1558  history information is not available to the public.” The 
1559  department shall provide in each practitioner profile, for every 
1560  final disciplinary action taken against the practitioner, an 
1561  easy-to-read narrative description that explains the 
1562  administrative complaint filed against the practitioner and the 
1563  final disciplinary action imposed on the practitioner. The 
1564  department shall include a hyperlink to each final order listed 
1565  in its website report of dispositions of recent disciplinary 
1566  actions taken against practitioners. 
1567         Section 13. Section 456.0635, Florida Statutes, is amended 
1568  to read: 
1569         456.0635 Health care Medicaid fraud; disqualification for 
1570  license, certificate, or registration.— 
1571         (1) Medicaid Fraud in the practice of a health care 
1572  profession is prohibited. 
1573         (2) Each board within the jurisdiction of the department, 
1574  or the department if there is no board, shall refuse to admit a 
1575  candidate to any examination and refuse to issue or renew a 
1576  license, certificate, or registration to any applicant if the 
1577  candidate or applicant or any principal, officer, agent, 
1578  managing employee, or affiliated person of the applicant, has 
1579  been: 
1580         (a) Has been convicted of, or entered a plea of guilty or 
1581  nolo contendere to, regardless of adjudication, a felony under 
1582  chapter 409, chapter 817, chapter 893, or a similar felony 
1583  offense committed in another state or jurisdiction 21 U.S.C. ss. 
1584  801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and any 
1585  subsequent period of probation for such conviction or plea pleas 
1586  ended: more than 15 years prior to the date of the application; 
1587         1. For felonies of the first or second degree more than 15 
1588  years before the date of application. 
1589         2. For felonies of the third degree more than 10 years 
1590  before the date of application, except for felonies of the third 
1591  degree under s. 893.13(6)(a). 
1592         3. For felonies of the third degree under s. 893.13(6)(a), 
1593  more than 5 years before the date of application. 
1594         4. For felonies in which the defendant entered a plea of 
1595  guilty or nolo contendere in an agreement with the court to 
1596  enter a pretrial intervention or drug diversion program, the 
1597  department shall not approve or deny the application for a 
1598  license, certificate, or registration until the final resolution 
1599  of the case. 
1600         (b) Has been convicted of, or entered a plea of guilty or 
1601  nolo contendere to, regardless of adjudication, a felony under 
1602  21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the 
1603  sentence and any subsequent period of probation for such 
1604  conviction or plea ended more than 15 years before the date of 
1605  the application; 
1606         (c)(b) Has been terminated for cause from the Florida 
1607  Medicaid program pursuant to s. 409.913, unless the applicant 
1608  has been in good standing with the Florida Medicaid program for 
1609  the most recent 5 years; 
1610         (d)(c) Has been terminated for cause, pursuant to the 
1611  appeals procedures established by the state or Federal 
1612  Government, from any other state Medicaid program or the federal 
1613  Medicare program, unless the applicant has been in good standing 
1614  with a state Medicaid program or the federal Medicare program 
1615  for the most recent 5 years and the termination occurred at 
1616  least 20 years before prior to the date of the application; or. 
1617         (e) Is currently listed on the United States Department of 
1618  Health and Human Services Office of Inspector General’s List of 
1619  Excluded Individuals and Entities. 
1620         (f) This subsection does not apply to applicants for 
1621  initial licensure or certification who were enrolled in an 
1622  educational or training program on or before July 1, 2009, which 
1623  was recognized by a board or, if there is no board, recognized 
1624  by the department, and who applied for licensure after July 1, 
1625  2009. 
1626         (3) Each board within the jurisdiction of the department, 
1627  or the department if there is no board, shall refuse to renew a 
1628  license, certificate, or registration of any applicant if the 
1629  candidate or applicant or any principal, officer, agent, 
1630  managing employee, or affiliated person of the applicant: 
1631         (a) Has been convicted of, or entered a plea of guilty or 
1632  nolo contendere to, regardless of adjudication, a felony under: 
1633  chapter 409, chapter 817, chapter 893, or a similar felony 
1634  offense committed in another state or jurisdiction since July 1, 
1635  2009. 
1636         (b) Has been convicted of, or entered a plea of guilty or 
1637  nolo contendere to, regardless of adjudication, a felony under 
1638  21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396 since July 1, 
1639  2009. 
1640         (c) Has been terminated for cause from the Florida Medicaid 
1641  program pursuant to s. 409.913, unless the applicant has been in 
1642  good standing with the Florida Medicaid program for the most 
1643  recent 5 years. 
1644         (d) Has been terminated for cause, pursuant to the appeals 
1645  procedures established by the state, from any other state 
1646  Medicaid program, unless the applicant has been in good standing 
1647  with a state Medicaid program for the most recent 5 years and 
1648  the termination occurred at least 20 years before the date of 
1649  the application. 
1650         (e) Is currently listed on the United States Department of 
1651  Health and Human Services Office of Inspector General’s List of 
1652  Excluded Individuals and Entities. 
1653         (f) For felonies in which the defendant entered a plea of 
1654  guilty or nolo contendere in an agreement with the court to 
1655  enter a pretrial intervention or drug diversion program, the 
1656  department shall not approve or deny the application for a 
1657  renewal of a license, certificate, or registration until the 
1658  final resolution of the case. 
1659         (4)(3) Licensed health care practitioners shall report 
1660  allegations of Medicaid fraud to the department, regardless of 
1661  the practice setting in which the alleged Medicaid fraud 
1662  occurred. 
1663         (5)(4) The acceptance by a licensing authority of a 
1664  candidate’s relinquishment of a license which is offered in 
1665  response to or anticipation of the filing of administrative 
1666  charges alleging Medicaid fraud or similar charges constitutes 
1667  the permanent revocation of the license. 
1668         (6) The department shall adopt rules to administer the 
1669  provisions of this section related to denial of licensure 
1670  renewal. 
1671         Section 14. Paragraph (kk) of subsection (1) of section 
1672  456.072, Florida Statutes, is amended to read: 
1673         456.072 Grounds for discipline; penalties; enforcement.— 
1674         (1) The following acts shall constitute grounds for which 
1675  the disciplinary actions specified in subsection (2) may be 
1676  taken: 
1677         (kk) Being terminated from the state Medicaid program 
1678  pursuant to s. 409.913 or, any other state Medicaid program, or 
1679  excluded from the federal Medicare program, unless eligibility 
1680  to participate in the program from which the practitioner was 
1681  terminated has been restored. 
1682         Section 15. Subsection (13) of section 456.073, Florida 
1683  Statutes, is amended to read: 
1684         456.073 Disciplinary proceedings.—Disciplinary proceedings 
1685  for each board shall be within the jurisdiction of the 
1686  department. 
1687         (13) Notwithstanding any provision of law to the contrary, 
1688  an administrative complaint against a licensee shall be filed 
1689  within 6 years after the time of the incident or occurrence 
1690  giving rise to the complaint against the licensee. If such 
1691  incident or occurrence involved fraud related to the Medicaid 
1692  program, criminal actions, diversion of controlled substances, 
1693  sexual misconduct, or impairment by the licensee, this 
1694  subsection does not apply to bar initiation of an investigation 
1695  or filing of an administrative complaint beyond the 6-year 
1696  timeframe. In those cases covered by this subsection in which it 
1697  can be shown that fraud, concealment, or intentional 
1698  misrepresentation of fact prevented the discovery of the 
1699  violation of law, the period of limitations is extended forward, 
1700  but in no event to exceed 12 years after the time of the 
1701  incident or occurrence. 
1702         Section 16. Subsection (1) of section 456.074, Florida 
1703  Statutes, is amended to read: 
1704         456.074 Certain health care practitioners; immediate 
1705  suspension of license.— 
1706         (1) The department shall issue an emergency order 
1707  suspending the license of any person licensed in a profession as 
1708  defined in this chapter under chapter 458, chapter 459, chapter 
1709  460, chapter 461, chapter 462, chapter 463, chapter 464, chapter 
1710  465, chapter 466, or chapter 484 who pleads guilty to, is 
1711  convicted or found guilty of, or who enters a plea of nolo 
1712  contendere to, regardless of adjudication, to: 
1713         (a) A felony under chapter 409, chapter 812, chapter 817, 
1714  or chapter 893, chapter 895, chapter 896, or under 21 U.S.C. ss. 
1715  801-970, or under 42 U.S.C. ss. 1395-1396; or 
1716         (b) A misdemeanor or felony under 18 U.S.C. s. 669, ss. 
1717  285-287, s. 371, s. 1001, s. 1035, s. 1341, s. 1343, s. 1347, s. 
1718  1349, or s. 1518 or 42 U.S.C. ss. 1320a-7b, relating to the 
1719  Medicaid program. 
1720         Section 17. Paragraph (q) of subsection (2) of section 
1721  499.01, Florida Statutes, is amended to read: 
1722         499.01 Permits.— 
1723         (2) The following permits are established: 
1724         (q) Device manufacturer permit.—A device manufacturer 
1725  permit is required for any person that engages in the 
1726  manufacture, repackaging, or assembly of medical devices for 
1727  human use in this state, except that a permit is not required 
1728  if: 
1729         1. The person does not manufacture, repackage, or assemble 
1730  any medical devices or components for such devices, except those 
1731  devices or components which are exempt from registration 
1732  pursuant to s. 499.015(8); or 
1733         2. The person is engaged only in manufacturing, 
1734  repackaging, or assembling a medical device pursuant to a 
1735  practitioner’s order for a specific patient. 
1736         a.1. A manufacturer or repackager of medical devices in 
1737  this state must comply with all appropriate state and federal 
1738  good manufacturing practices and quality system rules. 
1739         b.2. The department shall adopt rules related to storage, 
1740  handling, and recordkeeping requirements for manufacturers of 
1741  medical devices for human use. 
1742         Section 18. This act shall take effect July 1, 2010.