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S1340.................................................by HEALTH AND WELFARE
PUBLIC ASSISTANCE - PAYMENTS - Amends existing law relating to Medicaid to
revise definitions; to provide for documentation retention for a specified
time period; to provide for recovery by the Department of Health and
Welfare of payments made under any public assistance contract or provider
agreement; to revise grounds upon which the Department of Health and
Welfare may take certain action; to provide for exclusion from program
participation as a Medicaid provider; to provide for sanctions for
intentional program violations; and to provide an opportunity to appeal.
01/24 Senate intro - 1st rdg - to printing
01/25 Rpt prt - to Health/Wel
02/01 Rpt out - rec d/p - to 2nd rdg
02/04 2nd rdg - to 3rd rdg
02/06 3rd rdg - PASSED - 35-0-0
AYES -- Andreason, Bair, Bastian, Bilyeu, Broadsword, Burkett,
Cameron, Coiner, Corder, Darrington, Davis, Fulcher, Gannon, Geddes,
Goedde, Hammond, Heinrich, Hill, Jorgenson, Kelly, Keough, Langhorst,
Little, Lodge, Malepeai(Sagness), McGee, McKague, McKenzie, Pearce,
Richardson, Schroeder, Siddoway, Stegner, Stennett(Thorson), Werk
NAYS -- None
Absent and excused -- None
Floor Sponsor - Hammond
Title apvd - to House
02/07 House intro - 1st rdg - to Health/Wel
03/11 Rpt out - rec d/p - to 2nd rdg
03/12 2nd rdg - to 3rd rdg
03/13 3rd rdg - PASSED - 66-1-3
AYES -- Anderson, Andrus, Barrett, Bayer, Bedke, Bell, Black, Block,
Bock, Boe, Bolz, Bowers, Brackett, Bradford, Chadderdon, Chavez,
Chew, Clark, Collins, Crane, Durst, Eskridge, Hagedorn, Hart,
Henbest, Henderson, Jaquet, Killen, King, Kren, Labrador, Lake,
LeFavour, Loertscher, Luker, Marriott, Mathews, McGeachin, Mortimer,
Moyle, Nielsen, Nonini, Pasley-Stuart, Patrick, Pence, Raybould,
Ringo, Roberts, Ruchti, Rusche, Sayler, Schaefer, Shepherd(02),
Shepherd(08), Shirley, Shively, Smith(30), Smith(24), Stevenson,
Thayn, Thomas, Vander Woude, Wills, Wood(27), Wood(35), Mr. Speaker
NAYS -- Trail
Absent and excused -- Bilbao, Harwood, Snodgrass
Floor Sponsor - Luker
Title apvd - to Senate
03/14 To enrol
03/17 Rpt enrol - Pres signed - Sp signed
03/18 To Governor
03/18 Governor signed
Session Law Chapter 187
Effective: 07/01/08
]]]] LEGISLATURE OF THE STATE OF IDAHO ]]]] Fifty-ninth Legislature Second Regular Session - 2008IN THE SENATE SENATE BILL NO. 1340 BY HEALTH AND WELFARE COMMITTEE 1 AN ACT 2 RELATING TO MEDICAID; AMENDING SECTION 56-209h, IDAHO CODE, TO REVISE DEFINI- 3 TIONS, TO DEFINE ADDITIONAL TERMS, TO PROVIDE FOR DOCUMENTATION RETENTION 4 FOR A SPECIFIED TIME PERIOD, TO PROVIDE FOR RECOVERY BY THE DEPARTMENT OF 5 HEALTH AND WELFARE OF PAYMENTS MADE UNDER ANY PUBLIC ASSISTANCE CONTRACT 6 OR PROVIDER AGREEMENT, TO REVISE GROUNDS UPON WHICH THE DEPARTMENT MAY 7 TAKE CERTAIN ACTIONS, TO PROVIDE FOR EXCLUSION FROM PROGRAM PARTICIPATION 8 AS A MEDICAID PROVIDER, TO PROVIDE FOR SANCTIONS FOR INTENTIONAL PROGRAM 9 VIOLATIONS AND TO PROVIDE AN OPPORTUNITY TO APPEAL. 10 Be It Enacted by the Legislature of the State of Idaho: 11 SECTION 1. That Section 56-209h, Idaho Code, be, and the same is hereby 12 amended to read as follows: 13 56-209h. ADMINISTRATIVE REMEDIES. (1) Definitions. For purposes of this 14 section: 15 (a) "Abuse" or "abusive" means provider practices that are inconsistent 16 with sound fiscal, business, child care or medical practices, and result 17 in an unnecessary cost tothe medicala public assistance program, in 18 reimbursement for services that are not medically necessary or that fail 19 to meet professionally recognized standards for health care, or in physi- 20 cal harm, pain or mental anguish to amedicalpublic assistance recipient. 21 (b) "Claim" means any request or demand for payment,ofor document sub- 22 mitted to initiate payment, for items or services provided underthe23state's medicala public assistance program, whether under a contract or 24 otherwise. 25 (c) "Fraud" or "fraudulent" means an intentional deception or misrepre- 26 sentation made by a person with the knowledge that the deception could 27 result in some unauthorized benefit to himself or some other person. 28 (d) "Intentional program violation" means intentionally false or mislead- 29 ing action, omission or statement made in order to qualify as a provider 30 or recipient in a public assistance program. 31 (e) "Knowingly," "known" or "with knowledge" means that a person, with 32 respect to information or an action: 33 (i) Has actual knowledge of the information or action; or 34 (ii) Acts in deliberate ignorance of the truth or falsity of the 35 information or the correctness or incorrectness of the action; or 36 (iii) Acts in reckless disregard of the truth or falsity of the 37 information or the correctness or incorrectness of the action. 38 (ef) "Managing employee" means a general manager, business manager, 39 administrator, director or other individual who exercises operational or 40 managerial control over, or who directly or indirectly conducts the day- 41 to-day operation of, an institution, organization or agency. 42 (fg) "Medicaid fraud control unit" means that medicaid fraud control unit 43 as provided for in section 56-226, Idaho Code. 2 1 (gh) "Ownership or control interest" means a person or entity that: 2 (i) Has an ownership interest totaling twenty-five percent (25%) or 3 more in an entity; or 4 (ii) Is an officer or director of an entity that is organized as a 5 corporation; or 6 (iii) Is a partner in an entity that is organized as a partnership; 7 or 8 (iv) Is a managing member in an entity that is organized as a lim- 9 ited liability company. 10 (i) "Provider" means an individual, organization, agency or other entity 11 providing items or services under a public assistance program. 12 (j) "Public assistance program" means assistance for which provision is 13 made in any federal or state law existing or hereafter enacted by the 14 state of Idaho or the congress of the United States by which payments are 15 made from the federal government to the state in aid, or in respect to 16 payment by the state for welfare purposes to any category of needy person, 17 and any other program of assistance for which provision for federal or 18 state funds for aid may from time to time be made. 19 (2) The department shall establish and operate an administrative fraud 20 control program to enforce violations of the provisions of this chapter and of 21 the state plan pursuant to subchapters XIX and XXI, chapter 7, title 42, 22 U.S.C., that are outside the scope of the duties of the medicaid fraud control 23 unit and to render and receive referrals from and to said unit. 24 (3) Review of documentation of services. All claims submitted by 25 providers for payment are subject to prepayment and postpayment review as des- 26 ignated by rule. Except as otherwise provided by rule, providers shall gener- 27 ate documentation at the time of service sufficient to support each claim, and 28 shall retain the documentation for a minimum of five (5) years from the date 29 the item or service was provided. The department or authorized agent shall be 30 given immediate access to such documentation upon written request. 31 (4) Immediate action. In the event that the department identifies a sus- 32 pected case of fraud or abuse and the department has reason to believe that 33 payments made during the investigation may be difficult or impractical to 34 recover, the department may suspend or withhold payments to the provider pend- 35 ing investigation. In the event that the department identifies a suspected 36 case of fraud or abuse and it determines that it is necessary to prevent or 37 avoid immediate danger to the public health or safety, the department may sum- 38 marily suspend a provider agreement pending investigation. When payments have 39 been suspended or withheld or a provider agreement suspended pending investi- 40 gation, the department shall provide for a hearing within thirty (30) days of 41 receipt of any duly filed notice of appeal. 42 (5) Recovery of payments. Upon referral of a matter from the medicaid 43 fraud control unit, or if it is determined by the department that any condi- 44 tion of payment contained in rule, regulation, statute, or provider agreement 45 was not met, the department may initiate administrative proceedings to recover 46 any payments made for items or services under any public assistance contract 47 or provider agreement the individual or entity has with the department. Inter- 48 est shall accrue on overpayments at the statutory rate set forth in section 49 28-22-104, Idaho Code, from the date of final determination of the amount owed 50 for items or services until the date of recovery. 51 (6) Provider status. The department may terminate the provider agreement 52 or otherwise deny provider status to any individual or entity who: 53 (a) Submits a claim with knowledge that the claim is incorrect, including 54 reporting costs as allowable which were known to be disallowed in a previ- 55 ous audit, unless the provider clearly indicates that the item is being 3 1 claimed to establish the basis for an appeal and each disputed item and 2 amount is specifically identified; or 3 (b) Submits a fraudulent claim; or 4 (c) Knowingly makes a false statement or representation of material fact 5 in any document required to be maintained or submitted to the department; 6 or 7 (d) Submits a claim for an item or service known to be medically unneces- 8 sary; or 9 (e) Fails to provide, upon written request by the department, immediate 10 access to documentation required to be maintained; or 11 (f) Fails repeatedly or substantially to comply with the rules and regu- 12 lations governing medical assistance payments or other public assistance 13 program payments; or 14 (g) Knowingly violates any material term or condition of its provider 15 agreement; or 16 (h) Has failed to repay, or was a "managing employee" or had an 17 "ownership or control interest" in any entity that has failed to repay, 18 any overpayments or claims previously found to have been obtained contrary 19 to statute, rule, regulation or provider agreement; or 20 (i) Has been found, or was a "managing employee" in any entity which has 21 been found, to have engaged in fraudulent conduct or abusive conduct in 22 connection with the delivery of health care or public assistance items or 23 services; or 24 (j) Fails to meet the qualifications specifically required by rule or by 25 any applicable licensing board. 26 Any individual or entity denied provider status under this section may be pre- 27 cluded from participating as a provider inthe medicalany public assistance 28 program for up to five (5) years from the date the department's action becomes 29 final. 30 (7) The department must refer all cases of suspected medicaid provider 31 fraud to the medicaid fraud control unit and shall promptly comply with any 32 request from the medicaid fraud control unit for access to and free copies of 33 any records or information kept by the department or its contractors, comput- 34 erized data stored by the department or its contractors, and any information 35 kept by providers to which the department is authorized access by law. 36 (8) Civil monetary penalties. The department may also assess civil mone- 37 tary penalties against a provider and any officer, director, owner, and/or 38 managing employee of a provider for conduct identified in subsections (6)(a) 39 through (6)(i) of this section. The amount of the penalties shall be up to one 40 thousand dollars ($1,000) for each item or service improperly claimed, except 41 that in the case of multiple penalties the department may reduce the penalties 42 to not less than twenty-five percent (25%) of the amount of each item or ser- 43 vice improperly claimed if an amount can be readily determined. Each line item 44 of a claim, or cost on a cost report is considered a separate claim. These 45 penalties are intended to be remedial, recovering at a minimum costs of inves- 46 tigation and administrative review, and placing the costs associated with non- 47 compliance on the offending provider. 48 (9) Exclusion. Any individual or entity convicted of a criminal offense 49 related to the delivery of an item or service under any state or federal pro- 50 gram shall be excluded from program participation as a medicaid provider for a 51 period of not less than ten (10) years. Unless otherwise provided in this sec- 52 tion or required by federal law, the department may exclude any individual or 53 entity for a period of not less than one (1) year for any conduct for which 54 the secretary of the department of health and human services or designee could 55 exclude an individual or entity. 4 1 (10) Sanction of individuals or entities. The department may sanction 2 individuals or entities by barring them from public assistance programs for 3 intentional program violations where the federal law allows sanctioning indi- 4 viduals from receiving assistance. Individuals or entities who are determined 5 to have committed an intentional program violation will be sanctioned from 6 receiving public assistance for a period of twelve (12) months for the first 7 violation, twenty-four (24) months for the second violation and permanently 8 for the third violation. 9 (11) Individuals or entities subject to administrative remedies as 10 described in subsections (4) through (10) of this section shall be provided 11 the opportunity to appeal pursuant to chapter 52, title 67, Idaho Code, and 12 the department's rules for contested cases. 13 (12) Adoption of rules. The department shall promulgate such rules as are 14 necessary to carry out the policies and purposes of this section.
STATEMENT OF PURPOSE
RS 17425
The Department of Health and Welfare currently investigates
fraud in its public assistance programs by providers and
applicants and addresses fraud and abuse through administrative
remedies. The Department’s current authority only addresses
administrative remedies associated with Medicaid providers and
the proposed revisions expand this authority to address all
public assistance programs and assist the Department with
protecting program resources when fraud or other misconduct is
identified in those programs. The Department currently enters
into provider agreements and reimburses providers in various
public assistance programs for services provided to eligible
clients. The Department currently lacks statutory authority to
terminate the provider agreements for fraud or misconduct for
any providers other than Medicaid providers. The Department
regulations currently allow the sanctioning of individuals or
entities for fraud, abuse, or misconduct in certain programs;
however the Department is lacking the necessary statutory
authority to sanction ICCP providers and applicants who commit
fraud. This proposed change will provide the necessary statutory
authority for those sanctions which are already promulgated in
regulations. This proposed legislation will also require all
public assistance vendors to maintain documentation necessary
for the Department to review services provided and will allow
Department staff immediate access to the documentation upon
written request.
FISCAL NOTE
The proposed legislation adds to, and clarifies the authority of
the Department to take administrative actions against
individuals and entities for public assistance fraud and abuse.
There is no anticipated fiscal impact to this proposed
legislation since the Department is currently conducting many of
these activities; this proposed legislation clarifies the
statutory authority of many practices already defined in
regulation.
CONTACT
Name: Mond Warren
Agency: Health and Welfare
Phone: 208-334-0609
STATEMENT OF PURPOSE/FISCAL NOTE S 1340