1998 Legislation
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HOUSE BILL NO. 742, As Amended – Medical asst, documentation, fraud

HOUSE BILL NO. 742, As Amended

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Daily Data Tracking History



H0742aa...............................................by HEALTH AND WELFARE
MEDICAL ASSISTANCE - Adds to existing law to provide a statement of
legislative findings, to establish requirements for documentation of
medical assistance services, to provide for suspension of payments or
provider agreements, to provide for recovery of payments for medical
assistance services, to provide penalties for abuse and fraud, to provide
for termination of provider agreements and to provide for exclusion from
participation as a provider.

02/17    House intro - 1st rdg - to printing
02/18    Rpt prt - to Health/Wel
03/05    Rpt out - to Gen Ord
03/06    Rpt out amen - to engros
03/09    Rpt engros - 1st rdg - to 2nd rdg as amen
03/10    2nd rdg - to 3rd rdg as amen
03/11    3rd rdg as amen - PASSED 59-1-10
      AYES -- Barraclough, Barrett, Bell, Bieter, Bivens, Black(15),
      Black(23), Boe, Callister, Campbell, Chase, Clark, Crane, Deal,
      Denney, Ellsworth, Field(13), Gagner, Geddes, Gould, Hadley, Hansen,
      Henbest, Hornbeck, Jaquet, Jones(9), Jones(22), Jones(20), Judd,
      Kellogg, Kendell, Kjellander, Kunz, Lake, Loertscher, Marley,
      McKague, Meyer, Miller, Pischner, Pomeroy, Reynolds, Richman,
      Ridinger, Robison, Sali, Schaefer, Stevenson, Stoicheff, Stone,
      Taylor, Tilman, Tippets, Trail, Watson, Wheeler, Wood, Zimmermann,
      Mr Speaker
      NAYS -- Mader
      Absent and excused -- Alltus, Bruneel, Crow, Cuddy, Field(20),
      Kempton, Linford, Mortensen, Newcomb, Stubbs
    Floor Sponsor - Black(23)
    Title apvd - to Senate
03/12    Senate intro - 1st rdg as amen - to Health/Wel
03/17    Rpt out - rec d/p - to 2nd rdg as amen
03/18    2nd rdg - to 3rd rdg as amen
03/19    3rd rdg as amen - PASSED - 35-0-0
      AYES -- Andreason, Boatright, Branch, Bunderson, Burtenshaw, Cameron,
      Crow, Danielson, Darrington, Diede, Dunklin, Frasure, Geddes, Hansen,
      Hawkins, Ingram, Ipsen, Keough, King, Lee, McLaughlin, Noh, Parry,
      Richardson, Riggs, Risch, Sandy, Schroeder, Sorensen, Stennett,
      Sweeney, Thorne, Twiggs, Wheeler, Whitworth
      NAYS -- None
      Absent and excused -- None
    Floor Sponsor - Crow
    Title apvd - to House
03/20    To enrol - rpt enrol - Sp signed
    Pres signed - to Governor
03/24    Governor signed
         Session Law Chapter 311
         Effective: 07/01/98

Bill Text


H0742


                                                                        
 ||||              LEGISLATURE OF THE STATE OF IDAHO             ||||
Fifty-fourth Legislature                 Second Regular Session - 1998
                                                                        

                             IN THE HOUSE OF REPRESENTATIVES

                              HOUSE BILL NO. 742, As Amended

                             BY HEALTH AND WELFARE COMMITTEE

 1                                        AN ACT
 2    RELATING TO MEDICAL ASSISTANCE PROGRAMS; TO PROVIDE A STATEMENT OF LEGISLATIVE
 3        FINDINGS; AND AMENDING CHAPTER 2, TITLE 56, IDAHO CODE, BY THE ADDITION OF
 4        A NEW SECTION 56-209h, IDAHO CODE, TO DEFINE TERMS, TO ESTABLISH  REQUIRE-
 5        MENTS  FOR  DOCUMENTATION  OF  MEDICAL ASSISTANCE SERVICES, TO PROVIDE FOR
 6        SUSPENSION OF PAYMENTS OR PROVIDER AGREEMENT, TO PROVIDE FOR  RECOVERY  OF
 7        PAYMENTS  FOR  MEDICAL ASSISTANCE SERVICES, TO PROVIDE TERMINATION OF PRO-
 8        VIDER AGREEMENTS, TO PROVIDE FOR PENALTIES FOR ABUSE AND FRAUD AND TO PRO-
 9        VIDE EXCLUSION FROM PARTICIPATION AS A PROVIDER.

10    Be It Enacted by the Legislature of the State of Idaho:

11        SECTION 1.  FINDINGS. The legislature finds that provider fraud and  abuse
12    in  medical assistance programs is a potential problem which demands effective
13    administrative remedies. This act is intended to provide explicit authority to
14    the Department of Health and Welfare to establish conditions of  payments,  to
15    suspend payments and impose interest charges, to terminate provider agreements
16    and  deny  provider  status, to impose civil monetary penalties and to exclude
17    certain individuals and entities.

18        SECTION 2.  That Chapter 2, Title 56, Idaho Code,  be,  and  the  same  is
19    hereby  amended  by  the addition thereto of a  NEW SECTION , to be
20    known and designated as Section 56-209h, Idaho Code, and to read as follows:

21        56-209h.  ADMINISTRATIVE REMEDIES. (1) Definitions. For purposes  of  this
22    section:
23        (a)  "Abuse"  or  "abusive" means provider practices that are inconsistent
24        with sound fiscal, business, or medical practices, and result in an unnec-
25        essary cost to the medical assistance program, in reimbursement  for  ser-
26        vices that are not medically necessary or that fail to meet professionally
27        recognized  standards for health care, or in physical harm, pain or mental
28        anguish to a medical assistance recipient.
29        (b)  "Claim" means any request or demand for payment of items or  services
30        under  the state's medical assistance program, whether under a contract or
31        otherwise.
32        (c)  "Fraud" or "Fraudulent" means an intentional deception  or  misrepre-
33        sentation  made  by  a  person with the knowledge that the deception could
34        result in some unauthorized benefit to himself or some other person.
35        (d)  "Knowingly," "known" or "with knowledge" means that  a  person,  with
36        respect to information or an action:
37             (i)   Has actual knowledge of the information or action; or
38             (ii)  Acts  in  deliberate  ignorance  of the truth or falsity of the
39             information or the correctness or incorrectness of the action; or
40             (iii) Acts in reckless disregard of  the  truth  or  falsity  of  the
41             information or the correctness or incorrectness of the action.
42        (e)  "Managing employee" means a general manager, business manager, admin-


                                      2

 1        istrator,  director or other individual who exercises operational or mana-
 2        gerial control over, or who directly or indirectly conducts the day-to-day
 3        operation of, an institution, organization or agency.
 4        (f)  "Ownership or control interest" means a person or entity that:
 5             (i)   Has an ownership interest totaling twenty-five percent (25%) or
 6             more in an entity; or
 7             (ii)  Is an officer or director of an entity that is organized  as  a
 8             corporation; or
 9             (iii) Is  a  partner in an entity that is organized as a partnership;
10             or
11             (iv)  Is a managing member in an entity that is organized as  a  lim-
12             ited liability company.
13        (2)  Documentation of services. All claims submitted by providers for pay-
14    ment  are  subject to prepayment and postpayment review as designated by rule.
15    Except as otherwise provided by rule, providers shall  generate  documentation
16    at  the  time of service sufficient to support each claim and shall retain the
17    documentation for a minimum of five (5) years from the date the item  or  ser-
18    vice was provided. The department or authorized agent shall be given immediate
19    access to such documentation upon written request.
20        (3)  Immediate  action. In the event that the department identifies a sus-
21    pected case of fraud or abuse and the department has reason  to  believe  that
22    payments  made  during  the  investigation  may be difficult or impractical to
23    recover, the department may suspend or withhold payments to the provider pend-
24    ing investigation. In the event that the  department  identifies  a  suspected
25    case  of  fraud  or abuse and it determines that it is necessary to prevent or
26    avoid immediate danger to the public health or safety, the department may sum-
27    marily suspend a provider agreement pending investigation. When payments  have
28    been  suspended or withheld or a provider agreement suspended pending investi-
29    gation, the department shall provide for a hearing within thirty (30) days  of
30    receipt of any duly filed notice of appeal.
31        (4)  Recovery  of payments. If it is determined that any condition of pay-
32    ment contained in rule, regulation, statute, or  provider  agreement  was  not
33    met,  the  department  may  recover  any  payments made for items or services.
34    Interest shall accrue on overpayments at the statutory rate set forth in  sec-
35    tion 28-22-104, Idaho Code, from the date of final determination of the amount
36    owed for items or services until the date of recovery.
37        (5)  Provider  status. The department may terminate the provider agreement
38    or otherwise deny provider status to any individual or entity who:
39        (a)  Submits a claim with knowledge that the claim is incorrect, including
40        reporting costs as allowable which were known to be disallowed in a previ-
41        ous audit, unless the provider clearly indicates that the  item  is  being
42        claimed  to  establish  the basis for an appeal and each disputed item and
43        amount is specifically identified; or
44        (b)  Submits a fraudulent claim; or
45        (c)  Knowingly makes a false statement or representation of material  fact
46        in  any document required to be maintained or submitted to the department;
47        or
48        (d)  Submits a claim for an item or service known to be medically unneces-
49        sary; or
50        (e)  Fails to provide, upon written request by the  department,  immediate
51        access to documentation required to be maintained; or
52        (f)  Fails  repeatedly or substantially to comply with the rules and regu-
53        lations governing medical assistance payments; or
54        (g)  Knowingly violates any material term or  condition  of  its  provider
55        agreement; or


                                      3

 1        (h)  Has  failed  to  repay,  or  was  a  "managing  employee"  or  had an
 2        "ownership or control interest" in any entity that has  failed  to  repay,
 3        any overpayments or claims previously found to have been obtained contrary
 4        to statute, rule, regulation or provider agreement; or
 5        (i)  Has  been found, or was a "managing employee" in any entity which has
 6        been found, to have engaged in fraudulent conduct or  abusive  conduct  in
 7        connection with the delivery of health care items or services; or
 8        (j)  Fails  to meet the qualifications specifically required by rule or by
 9        any applicable licensing board.
10    Any individual or entity denied provider status under this section may be pre-
11    cluded from participating as a provider in the medical assistance program  for
12    up to five (5) years from the date the department's action becomes final.
13        (6)  Civil  monetary penalties. The department may also assess civil mone-
14    tary penalties against a provider and any  officer,  director,  owner,  and/or
15    managing  employee  of a provider for conduct identified in subsections (5)(a)
16    through (5)(i) of this section. The amount of the penalties shall be up to one
17    thousand dollars ($1,000) for each item or service improperly claimed,  except
18    that in the case of multiple penalties the department may reduce the penalties
19    to  not less than twenty-five percent (25%) of the amount of each item or ser-
20    vice improperly claimed if an amount can be readily determined. Each line item
21    of a claim, or cost on a cost report is considered  a  separate  claim.  These
22    penalties  are  intended to be remedial, recovering costs of investigation and
23    administrative review, and placing the costs associated with noncompliance  on
24    the offending provider.
25        (7)  Exclusion.  Any  individual or entity convicted of a criminal offense
26    related to the delivery of an item or service under any state or federal  pro-
27    gram  shall  be  excluded  from program participation for a period of not less
28    than ten (10) years. Unless otherwise provided in this section or required  by
29    federal  law, the department may exclude any individual or entity for a period
30    of not less than one (1) year for any conduct for which the secretary  of  the
31    department  of health and human services or designee could exclude an individ-
32    ual or entity.
33        (8)  Adoption of rules. The department shall promulgate such rules as  are
34    necessary to carry out the policies and purposes of this section.

Statement of Purpose / Fiscal Impact


    





                          STATEMENT OF PURPOSE
    
                             RS 0 8 0 4 6C 2
                                    
    
    The purpose of this legislation is to provide explicit authority 
    and direction regarding the safeguarding of funds used in the 
    state's medical assistance program. It is the intent of the 
    Legislature to provide adequate remedies to recover payments that 
    are improperly claimed or paid. It is also the intent of the 
    Legislature to protect both state resources and individuals 
    receiving medical assistance from unprofessional, dishonest or 
    abusive providers by providing explicit authority to terminate 
    provider agreements, impose penalties, and exclude certain 
    providers and individuals.
    
                               FISCAL NOTE
    
    The legislation is expected to result in no additional cost to 
    the state.
    
    CONTACT: 
    
    Name: Kathleen Allyn
    Agency: Department of Health and 
    Welfare
    Phone: 334-5747
    
    STATEMENT OF PURPOSE/FISCAL NOTE
    
    H 742