Rep. Natalie A. Manley

Filed: 3/15/2017

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 3537

2    AMENDMENT NO. ______. Amend House Bill 3537 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Public Aid Code is amended by
5changing Section 12-13.1 as follows:
 
6    (305 ILCS 5/12-13.1)
7    Sec. 12-13.1. Inspector General.
8    (a) The Governor shall appoint, and the Senate shall
9confirm, an Inspector General who shall function within the
10Illinois Department of Public Aid (now Healthcare and Family
11Services) and report to the Governor. The term of the Inspector
12General shall expire on the third Monday of January, 1997 and
13every 4 years thereafter.
14    (b) In order to prevent, detect, and eliminate fraud,
15waste, abuse, mismanagement, and misconduct, the Inspector
16General shall oversee the Department of Healthcare and Family

 

 

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1Services' and the Department on Aging's integrity functions,
2which include, but are not limited to, the following:
3        (1) Investigation of misconduct by employees, vendors,
4    contractors and medical providers, except for allegations
5    of violations of the State Officials and Employees Ethics
6    Act which shall be referred to the Office of the Governor's
7    Executive Inspector General for investigation.
8        (2) Prepayment and post-payment audits of medical
9    providers related to ensuring that appropriate payments
10    are made for services rendered and to the prevention and
11    recovery of overpayments.
12        (3) Monitoring of quality assurance programs
13    administered by the Department of Healthcare and Family
14    Services and the Community Care Program administered by the
15    Department on Aging.
16        (4) Quality control measurements of the programs
17    administered by the Department of Healthcare and Family
18    Services and the Community Care Program administered by the
19    Department on Aging.
20        (5) Investigations of fraud or intentional program
21    violations committed by clients of the Department of
22    Healthcare and Family Services and the Community Care
23    Program administered by the Department on Aging.
24        (6) Actions initiated against contractors, vendors, or
25    medical providers for any of the following reasons:
26            (A) Violations of the medical assistance program

 

 

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1        and the Community Care Program administered by the
2        Department on Aging.
3            (B) Sanctions against providers brought in
4        conjunction with the Department of Public Health or the
5        Department of Human Services (as successor to the
6        Department of Mental Health and Developmental
7        Disabilities).
8            (C) Recoveries of assessments against hospitals
9        and long-term care facilities.
10            (D) Sanctions mandated by the United States
11        Department of Health and Human Services against
12        medical providers.
13            (E) Violations of contracts related to any
14        programs administered by the Department of Healthcare
15        and Family Services and the Community Care Program
16        administered by the Department on Aging.
17        (7) Representation of the Department of Healthcare and
18    Family Services at hearings with the Illinois Department of
19    Financial and Professional Regulation in actions taken
20    against professional licenses held by persons who are in
21    violation of orders for child support payments.
22    (b-5) At the request of the Secretary of Human Services,
23the Inspector General shall, in relation to any function
24performed by the Department of Human Services as successor to
25the Department of Public Aid, exercise one or more of the
26powers provided under this Section as if those powers related

 

 

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1to the Department of Human Services; in such matters, the
2Inspector General shall report his or her findings to the
3Secretary of Human Services.
4    (c) Notwithstanding, and in addition to, any other
5provision of law, the Inspector General shall have access to
6all information, personnel and facilities of the Department of
7Healthcare and Family Services and the Department of Human
8Services (as successor to the Department of Public Aid), their
9employees, vendors, contractors and medical providers and any
10federal, State or local governmental agency that are necessary
11to perform the duties of the Office as directly related to
12public assistance programs administered by those departments.
13No medical provider shall be compelled, however, to provide
14individual medical records of patients who are not clients of
15the programs administered by the Department of Healthcare and
16Family Services. State and local governmental agencies are
17authorized and directed to provide the requested information,
18assistance or cooperation.
19    For purposes of enhanced program integrity functions and
20oversight, and to the extent consistent with applicable
21information and privacy, security, and disclosure laws, State
22agencies and departments shall provide the Office of Inspector
23General access to confidential and other information and data,
24and the Inspector General is authorized to enter into
25agreements with appropriate federal agencies and departments
26to secure similar data. This includes, but is not limited to,

 

 

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1information pertaining to: licensure; certification; earnings;
2immigration status; citizenship; wage reporting; unearned and
3earned income; pension income; employment; supplemental
4security income; social security numbers; National Provider
5Identifier (NPI) numbers; the National Practitioner Data Bank
6(NPDB); program and agency exclusions; taxpayer identification
7numbers; tax delinquency; corporate information; and death
8records.
9    The Inspector General shall enter into agreements with
10State agencies and departments, and is authorized to enter into
11agreements with federal agencies and departments, under which
12such agencies and departments shall share data necessary for
13medical assistance program integrity functions and oversight.
14The Inspector General shall enter into agreements with State
15agencies and departments, and is authorized to enter into
16agreements with federal agencies and departments, under which
17such agencies shall share data necessary for recipient and
18vendor screening, review, and investigation, including but not
19limited to vendor payment and recipient eligibility
20verification. The Inspector General shall develop, in
21cooperation with other State and federal agencies and
22departments, and in compliance with applicable federal laws and
23regulations, appropriate and effective methods to share such
24data. The Inspector General shall enter into agreements with
25State agencies and departments, and is authorized to enter into
26agreements with federal agencies and departments, including,

 

 

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1but not limited to: the Secretary of State; the Department of
2Revenue; the Department of Public Health; the Department of
3Human Services; and the Department of Financial and
4Professional Regulation.
5    The Inspector General shall have the authority to deny
6payment, prevent overpayments, and recover overpayments.
7    The Inspector General shall have the authority to deny or
8suspend payment to, and deny, terminate, or suspend the
9eligibility of, any vendor who fails to grant the Inspector
10General timely access to full and complete records, including
11records of recipients under the medical assistance program for
12the most recent 6 years, in accordance with Section 140.28 of
13Title 89 of the Illinois Administrative Code, and other
14information for the purpose of audits, investigations, or other
15program integrity functions, after reasonable written request
16by the Inspector General.
17    (c-5) The Inspector General must perform all audits with as
18much transparency as possible and maintain due process
19throughout the audit process and any and all appeals of the
20audit process. The Inspector General must provide a clear,
21well-supported case in all audits. The Inspector General must
22also clearly inform providers of their rights in appealing all
23findings. The Inspector General shall, at a minimum, do the
24following:
25        (1) Inform a provider, at the time of notification of
26    an audit, of any and all laws, regulations, administrative

 

 

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1    rules, policies, and procedures which are tested and
2    reviewed as part of the audit.
3        (2) Identify and present in all final audit reports all
4    documentation supporting any findings that are sufficient
5    to allow a provider to clearly follow the decision making
6    process. The audit report must also include a sufficient
7    and clear narrative explaining how the documentation
8    presented supports the audit findings and the reasons for
9    disregarding any other documentary evidence to the
10    contrary. The narrative must clearly cite the relevant
11    legal authority applied in the finding.
12        (3) Prior to issuing a final audit report, honor a
13    request by a provider for a review by another auditor
14    different than the one issuing the findings.
15        (4) Clearly delineate in all final audit reports: (i)
16    the entire appeal process and (ii) the rights of the
17    provider as opposed to referencing administrative rules or
18    other legal authority. The final audit report must
19    specifically state any date deadlines and provide contact
20    information in case there are questions about the appeal.
21        (5) Allow a provider the option of having any and all
22    hearings in Springfield. The Inspector General may not
23    require holding any and all hearings in Chicago. The
24    location of hearings must not be used as an obstacle to
25    allowing a provider to exercise its rights to appeal.
26    (d) The Inspector General shall serve as the Department of

 

 

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1Healthcare and Family Services' primary liaison with law
2enforcement, investigatory and prosecutorial agencies,
3including but not limited to the following:
4        (1) The Department of State Police.
5        (2) The Federal Bureau of Investigation and other
6    federal law enforcement agencies.
7        (3) The various Inspectors General of federal agencies
8    overseeing the programs administered by the Department of
9    Healthcare and Family Services.
10        (4) The various Inspectors General of any other State
11    agencies with responsibilities for portions of programs
12    primarily administered by the Department of Healthcare and
13    Family Services.
14        (5) The Offices of the several United States Attorneys
15    in Illinois.
16        (6) The several State's Attorneys.
17        (7) The offices of the Centers for Medicare and
18    Medicaid Services that administer the Medicare and
19    Medicaid integrity programs.
20    The Inspector General shall meet on a regular basis with
21these entities to share information regarding possible
22misconduct by any persons or entities involved with the public
23aid programs administered by the Department of Healthcare and
24Family Services.
25    (e) All investigations conducted by the Inspector General
26shall be conducted in a manner that ensures the preservation of

 

 

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1evidence for use in criminal prosecutions. If the Inspector
2General determines that a possible criminal act relating to
3fraud in the provision or administration of the medical
4assistance program has been committed, the Inspector General
5shall immediately notify the Medicaid Fraud Control Unit. If
6the Inspector General determines that a possible criminal act
7has been committed within the jurisdiction of the Office, the
8Inspector General may request the special expertise of the
9Department of State Police. The Inspector General may present
10for prosecution the findings of any criminal investigation to
11the Office of the Attorney General, the Offices of the several
12United States Attorneys in Illinois or the several State's
13Attorneys.
14    (f) To carry out his or her duties as described in this
15Section, the Inspector General and his or her designees shall
16have the power to compel by subpoena the attendance and
17testimony of witnesses and the production of books, electronic
18records and papers as directly related to public assistance
19programs administered by the Department of Healthcare and
20Family Services or the Department of Human Services (as
21successor to the Department of Public Aid). No medical provider
22shall be compelled, however, to provide individual medical
23records of patients who are not clients of the Medical
24Assistance Program.
25    (g) The Inspector General shall report all convictions,
26terminations, and suspensions taken against vendors,

 

 

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1contractors and medical providers to the Department of
2Healthcare and Family Services and to any agency responsible
3for licensing or regulating those persons or entities.
4    (h) The Inspector General shall make annual reports,
5findings, and recommendations regarding the Office's
6investigations into reports of fraud, waste, abuse,
7mismanagement, or misconduct relating to any programs
8administered by the Department of Healthcare and Family
9Services or the Department of Human Services (as successor to
10the Department of Public Aid) to the General Assembly and the
11Governor. These reports shall include, but not be limited to,
12the following information:
13        (1) Aggregate provider billing and payment
14    information, including the number of providers at various
15    Medicaid earning levels.
16        (2) The number of audits of the medical assistance
17    program and the dollar savings resulting from those audits.
18        (3) The number of prescriptions rejected annually
19    under the Department of Healthcare and Family Services'
20    Refill Too Soon program and the dollar savings resulting
21    from that program.
22        (4) Provider sanctions, in the aggregate, including
23    terminations and suspensions.
24        (5) A detailed summary of the investigations
25    undertaken in the previous fiscal year. These summaries
26    shall comply with all laws and rules regarding maintaining

 

 

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1    confidentiality in the public aid programs.
2    (i) Nothing in this Section shall limit investigations by
3the Department of Healthcare and Family Services or the
4Department of Human Services that may otherwise be required by
5law or that may be necessary in their capacity as the central
6administrative authorities responsible for administration of
7their agency's programs in this State.
8    (j) The Inspector General may issue shields or other
9distinctive identification to his or her employees not
10exercising the powers of a peace officer if the Inspector
11General determines that a shield or distinctive identification
12is needed by an employee to carry out his or her
13responsibilities.
14(Source: P.A. 97-689, eff. 6-14-12; 98-8, eff. 5-3-13.)".