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Sen. Kwame Raoul
Filed: 3/15/2013
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1 | | AMENDMENT TO SENATE BILL 1330
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2 | | AMENDMENT NO. ______. Amend Senate Bill 1330 by replacing |
3 | | everything after the enacting clause with the following:
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4 | | "Section 5. The Illinois Public Aid Code is amended by |
5 | | changing Section 12-4.25 as follows:
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6 | | (305 ILCS 5/12-4.25) (from Ch. 23, par. 12-4.25)
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7 | | Sec. 12-4.25. Medical assistance program; vendor |
8 | | participation.
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9 | | (A) The Illinois Department may deny, suspend, or
terminate |
10 | | the eligibility of any person, firm, corporation, association,
|
11 | | agency, institution or other legal entity to participate as a |
12 | | vendor of
goods or services to recipients under the medical |
13 | | assistance program
under Article V, or may exclude any such
|
14 | | person or entity from participation as such a vendor, and may
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15 | | deny, suspend, or recover payments, if after reasonable notice |
16 | | and opportunity for a
hearing the Illinois Department finds:
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1 | | (a) Such vendor is not complying with the Department's |
2 | | policy or
rules and regulations, or with the terms and |
3 | | conditions prescribed by
the Illinois Department in its |
4 | | vendor agreement, which document shall be
developed by the |
5 | | Department as a result of negotiations with each vendor
|
6 | | category, including physicians, hospitals, long term care |
7 | | facilities,
pharmacists, optometrists, podiatrists and |
8 | | dentists setting forth the
terms and conditions applicable |
9 | | to the participation of each vendor
group in the program; |
10 | | or
|
11 | | (b) Such vendor has failed to keep or make available |
12 | | for inspection,
audit or copying, after receiving a written |
13 | | request from the Illinois
Department, such records |
14 | | regarding payments claimed for providing
services. This |
15 | | section does not require vendors to make available
patient |
16 | | records of patients for whom services are not reimbursed |
17 | | under
this Code; or
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18 | | (c) Such vendor has failed to furnish any information |
19 | | requested by
the Department regarding payments for |
20 | | providing goods or services; or
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21 | | (d) Such vendor has knowingly made, or caused to be |
22 | | made, any false
statement or representation of a material |
23 | | fact in connection with the
administration of the medical |
24 | | assistance program; or
|
25 | | (e) Such vendor has furnished goods or services to a |
26 | | recipient which
are (1) in excess of need, (2) harmful, or
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1 | | (3) of grossly inferior quality, all of such determinations |
2 | | to be based
upon competent medical judgment and |
3 | | evaluations; or
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4 | | (f) The vendor; a person with management |
5 | | responsibility for a
vendor; an officer or person owning, |
6 | | either directly or indirectly, 5%
or more of the shares of |
7 | | stock or other evidences of ownership in a
corporate |
8 | | vendor; an owner of a sole proprietorship which is a |
9 | | vendor;
or a partner in a partnership which is a vendor, |
10 | | either:
|
11 | | (1) was previously terminated, suspended, or |
12 | | excluded from participation in the Illinois
medical |
13 | | assistance program, or was terminated, suspended, or |
14 | | excluded from participation in another state or |
15 | | federal medical assistance or health care program; or
|
16 | | (2) was a person with management responsibility |
17 | | for a vendor
previously terminated, suspended, or |
18 | | excluded from participation in the Illinois medical |
19 | | assistance
program, or terminated, suspended, or |
20 | | excluded from participation in another state or |
21 | | federal medical assistance or health care program
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22 | | during the time of conduct which was the basis for
that |
23 | | vendor's termination, suspension, or exclusion; or
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24 | | (3) was an officer, or person owning, either |
25 | | directly or indirectly,
5% or more of the shares of |
26 | | stock or other evidences of ownership in a corporate or |
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1 | | limited liability company vendor
previously |
2 | | terminated, suspended, or excluded from participation |
3 | | in the Illinois medical assistance
program, or |
4 | | terminated, suspended, or excluded from participation |
5 | | in a state or federal medical assistance or health care |
6 | | program
during the time of conduct which
was the basis |
7 | | for that vendor's termination, suspension, or |
8 | | exclusion; or
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9 | | (4) was an owner of a sole proprietorship or |
10 | | partner of a
partnership previously terminated, |
11 | | suspended, or excluded
from participation in the |
12 | | Illinois medical assistance program, or terminated, |
13 | | suspended, or excluded from participation in a state or |
14 | | federal medical assistance or health care program
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15 | | during the time of conduct
which was the basis for that |
16 | | vendor's termination, suspension, or exclusion; or
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17 | | (f-1) Such vendor has a delinquent debt owed to the |
18 | | Illinois Department; or
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19 | | (g) The vendor; a person with management |
20 | | responsibility for a
vendor; an officer or person owning, |
21 | | either directly or indirectly, 5%
or more of the shares of |
22 | | stock or other evidences of ownership in a
corporate or
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23 | | limited liability company vendor; an owner of a sole |
24 | | proprietorship which is a vendor;
or a partner in a |
25 | | partnership which is a vendor, either:
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26 | | (1) has engaged in practices prohibited by |
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1 | | applicable federal or
State law or regulation; or
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2 | | (2) was a person with management responsibility |
3 | | for a vendor at the
time that such vendor engaged in |
4 | | practices prohibited by applicable
federal or State |
5 | | law or regulation; or
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6 | | (3) was an officer, or person owning, either |
7 | | directly or indirectly,
5% or more of the shares of |
8 | | stock or other evidences of ownership in a
vendor at |
9 | | the time such vendor engaged in practices prohibited by
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10 | | applicable federal or State law or regulation; or
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11 | | (4) was an owner of a sole proprietorship or |
12 | | partner of a
partnership which was a vendor at the time |
13 | | such vendor engaged in
practices prohibited by |
14 | | applicable federal or State law or regulation; or
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15 | | (h) The direct or indirect ownership of the vendor |
16 | | (including the
ownership of a vendor that is a sole |
17 | | proprietorship, a partner's interest in a
vendor that is a |
18 | | partnership, or ownership of 5% or more of the shares of |
19 | | stock
or other
evidences of ownership in a corporate |
20 | | vendor) has been transferred by an
individual who is |
21 | | terminated, suspended, or excluded or barred from |
22 | | participating as a vendor to the
individual's spouse, |
23 | | child, brother, sister, parent, grandparent, grandchild,
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24 | | uncle, aunt, niece, nephew, cousin, or relative by |
25 | | marriage.
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26 | | (A-5) The Illinois Department may deny, suspend, or |
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1 | | terminate the
eligibility
of any person, firm, corporation, |
2 | | association, agency, institution, or other
legal entity to |
3 | | participate as a vendor of goods or services to recipients
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4 | | under the medical assistance program under Article V, or may
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5 | | exclude any such person or entity from participation as such a
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6 | | vendor, if, after reasonable
notice and opportunity for a |
7 | | hearing, the Illinois Department finds that the
vendor; a |
8 | | person with management responsibility for a vendor; an officer |
9 | | or
person owning, either directly or indirectly, 5% or more of |
10 | | the shares of stock
or other evidences of ownership in a |
11 | | corporate vendor; an owner of a sole
proprietorship that is a |
12 | | vendor; or a partner in a partnership that is a vendor
has been |
13 | | convicted of an offense based on fraud or willful
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14 | | misrepresentation related to any of
the following:
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15 | | (1) The medical assistance program under Article V of |
16 | | this Code.
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17 | | (2) A medical assistance or health care program in |
18 | | another state.
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19 | | (3) The Medicare program under Title XVIII of the |
20 | | Social Security Act.
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21 | | (4) The provision of health care services.
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22 | | (5) A violation of this Code, as provided in Article |
23 | | VIIIA, or another state or federal medical assistance |
24 | | program or health care program. |
25 | | (A-10) The Illinois Department may deny, suspend, or |
26 | | terminate the eligibility of any person, firm, corporation, |
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1 | | association, agency, institution, or other legal entity to |
2 | | participate as a vendor of goods or services to recipients |
3 | | under the medical assistance program under Article V, or may
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4 | | exclude any such person or entity from participation as such a
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5 | | vendor, if, after reasonable notice and opportunity for a |
6 | | hearing, the Illinois Department finds that (i) the vendor, |
7 | | (ii) a person with management responsibility for a vendor, |
8 | | (iii) an officer or person owning, either directly or |
9 | | indirectly, 5% or more of the shares of stock or other |
10 | | evidences of ownership in a corporate vendor, (iv) an owner of |
11 | | a sole proprietorship that is a vendor, or (v) a partner in a |
12 | | partnership that is a vendor has been convicted of an offense |
13 | | related to any of the following:
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14 | | (1) Murder.
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15 | | (2) A Class X felony under the Criminal Code of 1961 or |
16 | | the Criminal Code of 2012.
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17 | | (3) Sexual misconduct that may subject recipients to an |
18 | | undue risk of harm. |
19 | | (4) A criminal offense that may subject recipients to |
20 | | an undue risk of harm. |
21 | | (5) A crime of fraud or dishonesty. |
22 | | (6) A crime involving a controlled substance. |
23 | | (7) A misdemeanor relating to fraud, theft, |
24 | | embezzlement, breach of fiduciary responsibility, or other |
25 | | financial misconduct related to a health care program. |
26 | | (A-15) The Illinois Department may deny the eligibility of |
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1 | | any person, firm, corporation, association, agency, |
2 | | institution, or other legal entity to participate as a vendor |
3 | | of goods or services to recipients under the medical assistance |
4 | | program under Article V if, after reasonable notice and |
5 | | opportunity for a hearing, the Illinois Department finds: |
6 | | (1) The applicant or any person with management |
7 | | responsibility for the applicant; an officer or member of |
8 | | the board of directors of an applicant; an entity owning |
9 | | (directly or indirectly) 5% or more of the shares of stock |
10 | | or other evidences of ownership in a corporate vendor |
11 | | applicant; an owner of a sole proprietorship applicant; a |
12 | | partner in a partnership applicant; or a technical or other |
13 | | advisor to an applicant has a debt owed to the Illinois |
14 | | Department, and no payment arrangements acceptable to the |
15 | | Illinois Department have been made by the applicant. |
16 | | (2) The applicant or any person with management |
17 | | responsibility for the applicant; an officer or member of |
18 | | the board of directors of an applicant; an entity owning |
19 | | (directly or indirectly) 5% or more of the shares of stock |
20 | | or other evidences of ownership in a corporate vendor |
21 | | applicant; an owner of a sole proprietorship applicant; a |
22 | | partner in a partnership vendor applicant; or a technical |
23 | | or other advisor to an applicant was (i) a person with |
24 | | management responsibility, (ii) an officer or member of the |
25 | | board of directors of an applicant, (iii) an entity owning |
26 | | (directly or indirectly) 5% or more of the shares of stock |
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1 | | or other evidences of ownership in a corporate vendor, (iv) |
2 | | an owner of a sole proprietorship, (v) a partner in a |
3 | | partnership vendor, (vi) a technical or other advisor to a |
4 | | vendor, during a period of time where the conduct of that |
5 | | vendor resulted in a debt owed to the Illinois Department, |
6 | | and no payment arrangements acceptable to the Illinois |
7 | | Department have been made by that vendor. |
8 | | (3) There is a credible allegation of the use, |
9 | | transfer, or lease of assets of any kind to an applicant |
10 | | from a current or prior vendor who has a debt owed to the |
11 | | Illinois Department, no payment arrangements acceptable to |
12 | | the Illinois Department have been made by that vendor or |
13 | | the vendor's alternate payee, and the applicant knows or |
14 | | should have known of such debt. |
15 | | (4) There is a credible allegation of a transfer of |
16 | | management responsibilities, or direct or indirect |
17 | | ownership, to an applicant from a current or prior vendor |
18 | | who has a debt owed to the Illinois Department, and no |
19 | | payment arrangements acceptable to the Illinois Department |
20 | | have been made by that vendor or the vendor's alternate |
21 | | payee, and the applicant knows or should have known of such |
22 | | debt. |
23 | | (5) There is a credible allegation of the use, |
24 | | transfer, or lease of assets of any kind to an applicant |
25 | | who is a spouse, child, brother, sister, parent, |
26 | | grandparent, grandchild, uncle, aunt, niece, relative by |
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1 | | marriage, nephew, cousin, or relative of a current or prior |
2 | | vendor who has a debt owed to the Illinois Department and |
3 | | no payment arrangements acceptable to the Illinois |
4 | | Department have been made. |
5 | | (6) There is a credible allegation that the applicant's |
6 | | previous affiliations with a provider of medical services |
7 | | that has an uncollected debt, a provider that has been or |
8 | | is subject to a payment suspension under a federal health |
9 | | care program, or a provider that has been previously |
10 | | excluded from participation in the medical assistance |
11 | | program, poses a risk of fraud, waste, or abuse to the |
12 | | Illinois Department. |
13 | | As used in this subsection, "credible allegation" is |
14 | | defined to include an allegation from any source, including, |
15 | | but not limited to, fraud hotline complaints, claims data |
16 | | mining, patterns identified through provider audits, civil |
17 | | actions filed under the Illinois False Claims Act, and law |
18 | | enforcement investigations. An allegation is considered to be |
19 | | credible when it has indicia of reliability. |
20 | | (B) The Illinois Department shall deny, suspend or |
21 | | terminate the
eligibility of any person, firm, corporation, |
22 | | association, agency,
institution or other legal entity to |
23 | | participate as a vendor of goods or
services to recipients |
24 | | under the medical assistance program under
Article V, or may
|
25 | | exclude any such person or entity from participation as such a
|
26 | | vendor:
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1 | | (1) immediately, if such vendor is not properly |
2 | | licensed, certified, or authorized;
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3 | | (2) within 30 days of the date when such vendor's |
4 | | professional
license, certification or other authorization |
5 | | has been refused renewal, restricted,
revoked, suspended, |
6 | | or otherwise terminated; or
|
7 | | (3) if such vendor has been convicted of a violation of |
8 | | this Code, as
provided in Article VIIIA.
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9 | | (C) Upon termination, suspension, or exclusion of a vendor |
10 | | of goods or services from
participation in the medical |
11 | | assistance program authorized by this
Article, a person with |
12 | | management responsibility for such vendor during
the time of |
13 | | any conduct which served as the basis for that vendor's
|
14 | | termination, suspension, or exclusion is barred from |
15 | | participation in the medical assistance
program.
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16 | | Upon termination, suspension, or exclusion of a corporate |
17 | | vendor, the officers and persons
owning, directly or |
18 | | indirectly, 5% or more of the shares of stock or
other |
19 | | evidences of ownership in the vendor during the time of any
|
20 | | conduct which served as the basis for that vendor's |
21 | | termination, suspension, or exclusion are
barred from |
22 | | participation in the medical assistance program. A person who
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23 | | owns, directly or indirectly, 5% or more of the shares of stock |
24 | | or other
evidences of ownership in a terminated, suspended, or |
25 | | excluded vendor may not transfer his or
her ownership interest |
26 | | in that vendor to his or her spouse, child, brother,
sister, |
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1 | | parent, grandparent, grandchild, uncle, aunt, niece, nephew, |
2 | | cousin, or
relative by marriage.
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3 | | Upon termination, suspension, or exclusion of a sole |
4 | | proprietorship or partnership, the owner
or partners during the |
5 | | time of any conduct which served as the basis for
that vendor's |
6 | | termination, suspension, or exclusion are barred from |
7 | | participation in the medical
assistance program. The owner of a |
8 | | terminated, suspended, or excluded vendor that is a sole
|
9 | | proprietorship, and a partner in a terminated, suspended, or |
10 | | excluded vendor that is a partnership, may
not transfer his or |
11 | | her ownership or partnership interest in that vendor to his
or |
12 | | her spouse, child, brother, sister, parent, grandparent, |
13 | | grandchild, uncle,
aunt, niece, nephew, cousin, or relative by |
14 | | marriage.
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15 | | A person who owns, directly or indirectly, 5% or more of |
16 | | the shares of stock or other evidences of ownership in a |
17 | | corporate or limited liability company vendor who owes a debt |
18 | | to the Department, if that vendor has not made payment |
19 | | arrangements acceptable to the Department, shall not transfer |
20 | | his or her ownership interest in that vendor, or vendor assets |
21 | | of any kind, to his or her spouse, child, brother, sister, |
22 | | parent, grandparent, grandchild, uncle, aunt, niece, nephew, |
23 | | cousin, or relative by marriage. |
24 | | Rules adopted by the Illinois Department to implement these
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25 | | provisions shall specifically include a definition of the term
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26 | | "management responsibility" as used in this Section. Such |
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1 | | definition
shall include, but not be limited to, typical job |
2 | | titles, and duties and
descriptions which will be considered as |
3 | | within the definition of
individuals with management |
4 | | responsibility for a provider.
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5 | | A vendor or a prior vendor who has been terminated, |
6 | | excluded, or suspended from the medical assistance program, or |
7 | | from another state or federal medical assistance or health care |
8 | | program, and any individual currently or previously barred from |
9 | | the medical assistance program, or from another state or |
10 | | federal medical assistance or health care program, as a result |
11 | | of being an officer or a person owning, directly or indirectly, |
12 | | 5% or more of the shares of stock or other evidences of |
13 | | ownership in a corporate or limited liability company vendor |
14 | | during the time of any conduct which served as the basis for |
15 | | that vendor's termination, suspension, or exclusion, may be |
16 | | required to post a surety bond as part of a condition of |
17 | | enrollment or participation in the medical assistance program. |
18 | | The Illinois Department shall establish, by rule, the criteria |
19 | | and requirements for determining when a surety bond must be |
20 | | posted and the value of the bond. |
21 | | A vendor or a prior vendor who has a debt owed to the |
22 | | Illinois Department and any individual currently or previously |
23 | | barred from the medical assistance program, or from another |
24 | | state or federal medical assistance or health care program, as |
25 | | a result of being an officer or a person owning, directly or |
26 | | indirectly, 5% or more of the shares of stock or other |
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1 | | evidences of ownership in that corporate or limited liability |
2 | | company vendor during the time of any conduct which served as |
3 | | the basis for the debt, may be required to post a surety bond |
4 | | as part of a condition of enrollment or participation in the |
5 | | medical assistance program. The Illinois Department shall |
6 | | establish, by rule, the criteria and requirements for |
7 | | determining when a surety bond must be posted and the value of |
8 | | the bond. |
9 | | (D) If a vendor has been suspended from the medical |
10 | | assistance
program under Article V of the Code, the Director |
11 | | may require that such
vendor correct any deficiencies which |
12 | | served as the basis for the
suspension. The Director shall |
13 | | specify in the suspension order a specific
period of time, |
14 | | which shall not exceed one year from the date of the
order, |
15 | | during which a suspended vendor shall not be eligible to
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16 | | participate. At the conclusion of the period of suspension the |
17 | | Director
shall reinstate such vendor, unless he finds that such |
18 | | vendor has not
corrected deficiencies upon which the suspension |
19 | | was based.
|
20 | | If a vendor has been terminated, suspended, or excluded |
21 | | from the medical assistance program
under Article V, such |
22 | | vendor shall be barred from participation for at
least one |
23 | | year, except that if a vendor has been terminated, suspended, |
24 | | or excluded based on a
conviction of a
violation of Article |
25 | | VIIIA or a conviction of a felony based on fraud or a
willful |
26 | | misrepresentation related to (i) the medical assistance |
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1 | | program under
Article V, (ii) a federal or another state's |
2 | | medical assistance or health care program, or (iii) the |
3 | | provision of health care services, then
the vendor shall be |
4 | | barred from participation for 5 years or for the length of
the |
5 | | vendor's sentence for that conviction, whichever is longer. At |
6 | | the end of
one year a vendor who has been terminated, |
7 | | suspended, or excluded
may apply for reinstatement to the |
8 | | program. Upon proper application to
be reinstated such vendor |
9 | | may be deemed eligible by the Director
providing that such |
10 | | vendor meets the requirements for eligibility under
this Code. |
11 | | If such vendor is deemed not eligible for
reinstatement, he
|
12 | | shall be barred from again applying for reinstatement for one |
13 | | year from the
date his application for reinstatement is denied.
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14 | | A vendor whose termination, suspension, or exclusion from |
15 | | participation in the Illinois medical
assistance program under |
16 | | Article V was based solely on an action by a
governmental |
17 | | entity other than the Illinois Department may, upon |
18 | | reinstatement
by that governmental entity or upon reversal of |
19 | | the termination, suspension, or exclusion, apply for
|
20 | | rescission of the termination, suspension, or exclusion from |
21 | | participation in the Illinois medical
assistance program. Upon |
22 | | proper application for rescission, the vendor may be
deemed |
23 | | eligible by the Director if the vendor meets the requirements |
24 | | for
eligibility under this Code.
|
25 | | If a vendor has been terminated, suspended, or excluded and |
26 | | reinstated to the medical assistance
program under Article V |
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1 | | and the vendor is terminated, suspended, or excluded a second |
2 | | or subsequent
time from the medical assistance program, the |
3 | | vendor shall be barred from
participation for at least 2 years, |
4 | | except that if a vendor has been
terminated, suspended, or |
5 | | excluded a second time based on a
conviction of a violation of |
6 | | Article VIIIA or a conviction of a felony based on
fraud or a |
7 | | willful misrepresentation related to (i) the medical |
8 | | assistance
program under Article V, (ii) a federal or another |
9 | | state's medical assistance or health care program, or (iii) the |
10 | | provision of health care
services, then the vendor shall be |
11 | | barred from participation for life. At
the end of 2 years, a |
12 | | vendor who has
been terminated, suspended, or excluded may |
13 | | apply for reinstatement to the program. Upon application
to be |
14 | | reinstated, the vendor may be deemed eligible if the vendor |
15 | | meets the
requirements for eligibility under this Code. If the |
16 | | vendor is deemed not
eligible for reinstatement, the vendor |
17 | | shall be barred from again applying for
reinstatement for 2 |
18 | | years from the date the vendor's application for
reinstatement |
19 | | is denied.
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20 | | (E) The Illinois Department may recover money improperly or
|
21 | | erroneously paid, or overpayments, either by setoff, crediting |
22 | | against
future billings or by requiring direct repayment to the |
23 | | Illinois
Department. The Illinois Department may suspend or |
24 | | deny payment, in whole or in part, if such payment would be |
25 | | improper or erroneous or would otherwise result in overpayment. |
26 | | (1) Payments may be suspended, denied, or recovered |
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1 | | from a vendor or alternate payee: (i) for services rendered |
2 | | in violation of the Illinois Department's provider |
3 | | notices, statutes, rules, and regulations; (ii) for |
4 | | services rendered in violation of the terms and conditions |
5 | | prescribed by the Illinois Department in its vendor |
6 | | agreement; (iii) for any vendor who fails to grant the |
7 | | Office of Inspector General timely access to full and |
8 | | complete records, including, but not limited to, records |
9 | | relating to recipients under the medical assistance |
10 | | program for the most recent 6 years, in accordance with |
11 | | Section 140.28 of Title 89 of the Illinois Administrative |
12 | | Code, and other information for the purpose of audits, |
13 | | investigations, or other program integrity functions, |
14 | | after reasonable written request by the Inspector General; |
15 | | this subsection (E) does not require vendors to make |
16 | | available the medical records of patients for whom services |
17 | | are not reimbursed under this Code or to provide access to |
18 | | medical records more than 6 years old; (iv) when the vendor |
19 | | has knowingly made, or caused to be made, any false |
20 | | statement or representation of a material fact in |
21 | | connection with the administration of the medical |
22 | | assistance program; or (v) when the vendor previously |
23 | | rendered services while terminated, suspended, or excluded |
24 | | from participation in the medical assistance program or |
25 | | while terminated or excluded from participation in another |
26 | | state or federal medical assistance or health care program. |
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| | 09800SB1330sam001 | - 18 - | LRB098 02585 KTG 43047 a |
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1 | | (2) Notwithstanding any other provision of law, if a |
2 | | vendor has the same taxpayer identification number |
3 | | (assigned under Section 6109 of the Internal Revenue Code |
4 | | of 1986) as is assigned to a vendor with past-due financial |
5 | | obligations to the Illinois Department, the Illinois |
6 | | Department may make any necessary adjustments to payments |
7 | | to that vendor in order to satisfy any past-due |
8 | | obligations, regardless of whether the vendor is assigned a |
9 | | different billing number under the medical assistance |
10 | | program.
|
11 | | If the Illinois Department establishes through an |
12 | | administrative
hearing that the overpayments resulted from the |
13 | | vendor
or alternate payee knowingly making, using, or causing |
14 | | to be made or used, a false record or statement to obtain |
15 | | payment or other benefit from the medical assistance program |
16 | | under Article V, the Department may
recover interest on the |
17 | | amount of the payment or other benefit at the rate of 5% per |
18 | | annum.
In addition to any other penalties that may be |
19 | | prescribed by law, such a vendor or alternate payee shall be |
20 | | subject to civil penalties consisting of an amount not to |
21 | | exceed 3 times the amount of payment or other benefit resulting |
22 | | from each such false record or statement, and the sum of $2,000 |
23 | | for each such false record or statement for payment or other |
24 | | benefit. For purposes of this paragraph,
"knowingly" means that |
25 | | a vendor or alternate payee with respect to information: (i) |
26 | | has
actual knowledge of the information, (ii) acts in |
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1 | | deliberate ignorance of the truth or falsity of the |
2 | | information, or (iii) acts in reckless disregard of the truth |
3 | | or falsity of the information. No proof of specific intent to |
4 | | defraud is required.
|
5 | | (E-5) Civil monetary penalties for improperly filed |
6 | | claims. |
7 | | (1) As used in this subsection (E-5): |
8 | | (a) "Knowingly" means that a person, with respect |
9 | | to
information:
(i) has actual knowledge of the |
10 | | information;
(ii) acts in deliberate ignorance of the |
11 | | truth or falsity of the
information; or
(iii) acts in |
12 | | reckless disregard of the truth or falsity of the
|
13 | | information. No proof of specific intent to defraud is |
14 | | required. |
15 | | (b) "Overpayment" means any funds that a person |
16 | | receives or
retains from the medical assistance |
17 | | program to which the person,
after applicable |
18 | | reconciliation, is not entitled under this Code. |
19 | | (c) "Remuneration" means the offer or transfer of |
20 | | items or
services for free or for other than fair |
21 | | market value by a
person; however, remuneration does |
22 | | not include items or services
of a nominal value of no |
23 | | more than $10 per item or service, or
$50 in the |
24 | | aggregate on an annual basis, or any other offer or
|
25 | | transfer of the items or services as determined by the
|
26 | | Department. |
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1 | | (d) "Should know" means that a person, with respect |
2 | | to
information:
(i) acts in deliberate ignorance of the |
3 | | truth or falsity
of the information; or
(ii) acts in |
4 | | reckless disregard of the truth or falsity of
the |
5 | | information. No proof of specific intent to defraud is |
6 | | required. |
7 | | (2) Any person (including a vendor, provider, |
8 | | organization, agency, or other entity, or an alternate |
9 | | payee thereof, but excluding a recipient) who: |
10 | | (a) knowingly presents or causes to be presented to |
11 | | an officer, employee, or agent of the Department or the |
12 | | State, a claim that the Department determines: |
13 | | (i) is for a medical or other item or service |
14 | | that the person knows or should know was not |
15 | | provided as claimed, including any person who |
16 | | engages in a pattern or practice of presenting or |
17 | | causing to be presented a claim for an item or |
18 | | service that is based on a code that the person |
19 | | knows or should know will result in a greater |
20 | | payment to the person than the code the person |
21 | | knows or should know is applicable to the item or |
22 | | service actually provided; |
23 | | (ii) is for a medical or other item or service |
24 | | and the person knows or should know that the claim |
25 | | is false or fraudulent; |
26 | | (iii) is presented for a physician's service, |
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1 | | or an item or service incident to a physician's |
2 | | service, by a person who knows or should know that |
3 | | the individual who furnished, or supervised the |
4 | | furnishing of, the service: |
5 | | (AA) was not licensed as a physician; |
6 | | (BB) was licensed as a physician but such |
7 | | license had been obtained through a |
8 | | misrepresentation of material fact (including |
9 | | cheating on an examination required for |
10 | | licensing); or |
11 | | (CC) represented to the patient at the |
12 | | time the service was furnished that the |
13 | | physician was certified in a medical specialty |
14 | | by a medical specialty board, when the |
15 | | individual was not so certified; |
16 | | (iv) is for a medical or other item or service |
17 | | furnished during a period in which the person was |
18 | | excluded from the medical assistance program or a |
19 | | federal or state health care program under which |
20 | | the claim
was made pursuant to applicable law; or |
21 | | (v) is for a pattern of medical or other items |
22 | | or services that a person knows or should know are |
23 | | not medically necessary; |
24 | | (b) knowingly presents or causes to be presented to |
25 | | any person a request for payment which is in violation |
26 | | of the conditions for receipt
of vendor payments under |
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1 | | the medical assistance program under Section 11-13 of |
2 | | this Code; |
3 | | (c) knowingly gives or causes to be given to any |
4 | | person, with respect to medical assistance program |
5 | | coverage of inpatient hospital services, information |
6 | | that he or she knows or should know is false or |
7 | | misleading, and that could reasonably be expected to |
8 | | influence the decision when to discharge such person or |
9 | | other individual from the hospital; |
10 | | (d) in the case of a person who is not an |
11 | | organization, agency, or other entity, is excluded |
12 | | from participating in the medical assistance
program |
13 | | or a federal or state health care program and who, at |
14 | | the time
of a violation of this subsection (E-5): |
15 | | (i) retains a direct or indirect ownership or |
16 | | control interest in an entity that is |
17 | | participating in the medical assistance program or |
18 | | a federal or state health care program, and who |
19 | | knows or should know of the action constituting the |
20 | | basis for the exclusion; or |
21 | | (ii) is an officer or managing employee of such |
22 | | an entity; |
23 | | (e) offers or transfers remuneration to any |
24 | | individual eligible for benefits under the medical |
25 | | assistance program that such person knows or should |
26 | | know is likely to influence such individual to order or |
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1 | | receive from a particular vendor, provider, |
2 | | practitioner, or supplier any item or service for which |
3 | | payment may be made, in whole or in part, under the |
4 | | medical assistance program; |
5 | | (f) arranges or contracts (by employment or |
6 | | otherwise) with an individual or entity that the person |
7 | | knows or should know is excluded from participation in |
8 | | the medical assistance program or a federal or
state |
9 | | health care program, for the provision of items or |
10 | | services for which payment may be made under such a |
11 | | program; |
12 | | (g) commits an act described in subsection (b) or |
13 | | (c) of Section 8A-3; |
14 | | (h) knowingly makes, uses, or causes to be made or |
15 | | used, a false record
or statement material to a false |
16 | | or fraudulent claim for payment for
items and services |
17 | | furnished under the medical assistance program; |
18 | | (i) fails to grant timely access, upon reasonable |
19 | | request (as defined
by the Department), to the |
20 | | Inspector General, for the purpose of
audits, |
21 | | investigations, evaluations, or other statutory |
22 | | functions of
the Inspector General of the Department; |
23 | | (j) orders or prescribes a medical or other item or |
24 | | service during a
period in which the person was |
25 | | excluded from the medical assistance
program or a |
26 | | federal or state health care program, in the case where
|
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1 | | the person knows or should know that a claim for such |
2 | | medical or other
item or service will be made under |
3 | | such a program; |
4 | | (k) knowingly makes or causes to be made any false |
5 | | statement, omission, or misrepresentation of a |
6 | | material fact in any application, bid, or contract to |
7 | | participate or enroll as a vendor or provider of |
8 | | services or a supplier under the medical assistance |
9 | | program; |
10 | | (l) knows of an overpayment and does not report and |
11 | | return the
overpayment to the Department; |
12 | | shall be subject, in addition to any other penalties that |
13 | | may be prescribed by law, to a civil money penalty of not |
14 | | more than $10,000
for each item or service (or, in cases |
15 | | under paragraph (c), $15,000
for each individual with |
16 | | respect to whom false or misleading
information was given; |
17 | | in cases under paragraph (d), $10,000 for
each day the |
18 | | prohibited relationship occurs; in cases under paragraph
|
19 | | (g), $50,000 for each such act; in cases under paragraph
|
20 | | (h), $50,000 for each false record or statement; in cases |
21 | | under
paragraph (i), $15,000 for each day of the failure |
22 | | described in such
paragraph; or in cases under paragraph |
23 | | (k), $50,000 for each false
statement, omission, or |
24 | | misrepresentation of a material fact). In
addition, such a |
25 | | person shall be subject to an assessment of not more
than 3 |
26 | | times the amount claimed for each such item or service in |
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1 | | lieu
of damages sustained by State or the Department |
2 | | because of such claim
(or, in cases under paragraph (g), |
3 | | damages of not more than 3 times
the total amount of |
4 | | remuneration offered, paid, solicited, or received,
|
5 | | without regard to whether a portion of such remuneration |
6 | | was offered,
paid, solicited, or received for a lawful |
7 | | purpose; or in cases under
paragraph (k), an assessment of |
8 | | not more than 3 times the total
amount claimed for each |
9 | | item or service for which payment was made
based upon the |
10 | | application, bid, or contract containing the false
|
11 | | statement, omission, or misrepresentation of a material |
12 | | fact). |
13 | | (3) In addition, the Department may make a |
14 | | determination in the
same proceeding to exclude, |
15 | | terminate, suspend, or bar the person from
participation in |
16 | | the medical assistance program. |
17 | | (4) Prior to the imposition of any penalties or |
18 | | sanctions, the affected
person shall be afforded an
|
19 | | opportunity for a hearing after reasonable notice. The
|
20 | | Department shall establish hearing procedures by rule. |
21 | | Any final order, decision, or other determination made, |
22 | | issued, or executed by the Director under the provisions of |
23 | | this subsection, whereby a person is aggrieved, shall be |
24 | | subject to review in accordance with the provisions of the |
25 | | Administrative Review Law, and the rules adopted pursuant |
26 | | thereto, which shall apply to and govern all proceedings for |
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1 | | the judicial review of final administrative decisions of the |
2 | | Director. |
3 | | (F) The Illinois Department may withhold payments to any |
4 | | vendor
or alternate payee prior to or during the pendency of |
5 | | any audit or proceeding under this Section, and through the |
6 | | pendency of any administrative appeal or administrative review |
7 | | by any court proceeding. The Illinois Department shall
state by |
8 | | rule with as much specificity as practicable the conditions
|
9 | | under which payments will not be withheld under this Section. |
10 | | Payments may be denied for bills
submitted with service dates |
11 | | occurring during the pendency of a
proceeding, after a final |
12 | | decision has been rendered, or after the conclusion of any |
13 | | administrative appeal, where the final administrative decision |
14 | | is to terminate, exclude, or suspend
eligibility to participate |
15 | | in the medical assistance program. The
Illinois Department |
16 | | shall state by rule with as much specificity as
practicable the |
17 | | conditions under which payments will not be denied for
such |
18 | | bills.
The Illinois
Department shall state by rule a process |
19 | | and criteria by
which a vendor or alternate payee may request |
20 | | full or partial release of payments withheld under
this |
21 | | subsection. The Department must complete a proceeding under |
22 | | this Section
in a timely manner.
|
23 | | Notwithstanding recovery allowed under subsection (E) or |
24 | | this subsection (F), the Illinois Department may withhold |
25 | | payments to any vendor or alternate payee who is not properly |
26 | | licensed, certified, or in compliance with State or federal |
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1 | | agency regulations. Payments may be denied for bills submitted |
2 | | with service dates occurring during the period of time that a |
3 | | vendor is not properly licensed, certified, or in compliance |
4 | | with State or federal regulations. Facilities licensed under
|
5 | | the Nursing Home Care Act shall have payments denied or
|
6 | | withheld pursuant to subsection (I) of this Section. |
7 | | (F-5) The Illinois Department may temporarily withhold |
8 | | payments to
a vendor or alternate payee if any of the following |
9 | | individuals have been indicted or
otherwise charged under a law |
10 | | of the United States or this or any other state
with an offense |
11 | | that is based on alleged fraud or willful
misrepresentation on |
12 | | the part of the individual related to (i) the medical
|
13 | | assistance program under Article V of this Code, (ii) a federal |
14 | | or another state's medical assistance
or health care program, |
15 | | or (iii) the provision of health care services:
|
16 | | (1) If the vendor or alternate payee is a corporation: |
17 | | an officer of the corporation
or an individual who owns, |
18 | | either directly or indirectly, 5% or more
of the shares of |
19 | | stock or other evidence of ownership of the
corporation.
|
20 | | (2) If the vendor is a sole proprietorship: the owner |
21 | | of the sole
proprietorship.
|
22 | | (3) If the vendor or alternate payee is a partnership: |
23 | | a partner in the partnership.
|
24 | | (4) If the vendor or alternate payee is any other |
25 | | business entity authorized by law
to transact business in |
26 | | this State: an officer of the entity or an
individual who |
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1 | | owns, either directly or indirectly, 5% or more of the
|
2 | | evidences of ownership of the entity.
|
3 | | If the Illinois Department withholds payments to a vendor |
4 | | or alternate payee under this
subsection, the Department shall |
5 | | not release those payments to the vendor
or alternate payee
|
6 | | while any criminal proceeding related to the indictment or |
7 | | charge is pending
unless the Department determines that there |
8 | | is good cause to release the
payments before completion of the |
9 | | proceeding. If the indictment or charge
results in the |
10 | | individual's conviction, the Illinois Department shall retain
|
11 | | all withheld
payments, which shall be considered forfeited to |
12 | | the Department. If the
indictment or charge does not result in |
13 | | the individual's conviction, the
Illinois Department
shall |
14 | | release to the vendor or alternate payee all withheld payments.
|
15 | | (F-10) If the Illinois Department establishes that the |
16 | | vendor or alternate payee owes a debt to the Illinois |
17 | | Department, and the vendor or alternate payee subsequently |
18 | | fails to pay or make satisfactory payment arrangements with the |
19 | | Illinois Department for the debt owed, the Illinois Department |
20 | | may seek all remedies available under the law of this State to |
21 | | recover the debt, including, but not limited to, wage |
22 | | garnishment or the filing of claims or liens against the vendor |
23 | | or alternate payee. |
24 | | (F-15) Enforcement of judgment. |
25 | | (1) Any fine, recovery amount, other sanction, or costs |
26 | | imposed, or part of any fine, recovery amount, other |
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1 | | sanction, or cost imposed, remaining unpaid after the |
2 | | exhaustion of or the failure to exhaust judicial review |
3 | | procedures under the Illinois Administrative Review Law is |
4 | | a debt due and owing the State and may be collected using |
5 | | all remedies available under the law. |
6 | | (2) After expiration of the period in which judicial |
7 | | review under the Illinois Administrative Review Law may be |
8 | | sought for a final administrative decision, unless stayed |
9 | | by a court of competent jurisdiction, the findings, |
10 | | decision, and order of the Director may be enforced in the |
11 | | same manner as a judgment entered by a court of competent |
12 | | jurisdiction. |
13 | | (3) In any case in which any person or entity has |
14 | | failed to comply with a judgment ordering or imposing any |
15 | | fine or other sanction, any expenses incurred by the |
16 | | Illinois Department to enforce the judgment, including, |
17 | | but not limited to, attorney's fees, court costs, and costs |
18 | | related to property demolition or foreclosure, after they |
19 | | are fixed by a court of competent jurisdiction or the |
20 | | Director, shall be a debt due and owing the State and may |
21 | | be collected in accordance with applicable law. Prior to |
22 | | any expenses being fixed by a final administrative decision |
23 | | pursuant to this subsection (F-15), the Illinois |
24 | | Department shall provide notice to the individual or entity |
25 | | that states that the individual or entity shall appear at a |
26 | | hearing before the administrative hearing officer to |
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1 | | determine whether the individual or entity has failed to |
2 | | comply with the judgment. The notice shall set the date for |
3 | | such a hearing, which shall not be less than 7 days from |
4 | | the date that notice is served. If notice is served by |
5 | | mail, the 7-day period shall begin to run on the date that |
6 | | the notice was deposited in the mail. |
7 | | (4) Upon being recorded in the manner required by |
8 | | Article XII of the Code of Civil Procedure or by the |
9 | | Uniform Commercial Code, a lien shall be imposed on the |
10 | | real estate or personal estate, or both, of the individual |
11 | | or entity in the amount of any debt due and owing the State |
12 | | under this Section. The lien may be enforced in the same |
13 | | manner as a judgment of a court of competent jurisdiction. |
14 | | A lien shall attach to all property and assets of such |
15 | | person, firm, corporation, association, agency, |
16 | | institution, or other legal entity until the judgment is |
17 | | satisfied. |
18 | | (5) The Director may set aside any judgment entered by
|
19 | | default and set a new hearing date upon a petition filed at
|
20 | | any time (i) if the petitioner's failure to appear at the
|
21 | | hearing was for good cause, or (ii) if the petitioner
|
22 | | established that the Department did not provide proper
|
23 | | service of process. If any judgment is set aside pursuant
|
24 | | to this paragraph (5), the hearing officer shall have
|
25 | | authority to enter an order extinguishing any lien which
|
26 | | has been recorded for any debt due and owing the Illinois
|
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1 | | Department as a result of the vacated default judgment. |
2 | | (G) The provisions of the Administrative Review Law, as now |
3 | | or hereafter
amended, and the rules adopted pursuant
thereto, |
4 | | shall apply to and govern all proceedings for the judicial
|
5 | | review of final administrative decisions of the Illinois |
6 | | Department
under this Section. The term "administrative |
7 | | decision" is defined as in
Section 3-101 of the Code of Civil |
8 | | Procedure.
|
9 | | (G-5) Vendors who pose a risk of fraud, waste, abuse, or |
10 | | harm.
|
11 | | (1) Notwithstanding any other provision in this |
12 | | Section, the Department may terminate, suspend, or exclude |
13 | | vendors who pose a risk of fraud, waste, abuse, or harm |
14 | | from
participation in the medical assistance program prior
|
15 | | to an evidentiary hearing but after reasonable notice and |
16 | | opportunity to
respond as established by the Department by |
17 | | rule.
|
18 | | (2) Vendors who pose a risk of fraud, waste, abuse, or |
19 | | harm shall submit to a fingerprint-based criminal
|
20 | | background check on current and future information |
21 | | available in the State
system and current information |
22 | | available through the Federal Bureau of
Investigation's |
23 | | system by submitting all necessary fees and information in |
24 | | the
form and manner
prescribed by the Department of State |
25 | | Police. The following individuals shall
be subject to the |
26 | | check:
|
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1 | | (A) In the case of a vendor that is a corporation, |
2 | | every shareholder
who owns, directly or indirectly, 5% |
3 | | or more of the outstanding shares of
the corporation.
|
4 | | (B) In the case of a vendor that is a partnership, |
5 | | every partner.
|
6 | | (C) In the case of a vendor that is a sole |
7 | | proprietorship, the sole
proprietor.
|
8 | | (D) Each officer or manager of the vendor.
|
9 | | Each such vendor shall be responsible for payment of |
10 | | the cost of the
criminal background check.
|
11 | | (3) Vendors who pose a risk of fraud, waste, abuse, or |
12 | | harm may be
required to post a surety bond. The Department |
13 | | shall establish, by rule, the
criteria and requirements for |
14 | | determining when a surety bond must be posted and
the value |
15 | | of the bond.
|
16 | | (4) The Department, or its agents, may refuse to accept |
17 | | requests for authorization from specific vendors who pose a |
18 | | risk of fraud, waste, abuse, or harm, including |
19 | | prior-approval and
post-approval requests, if:
|
20 | | (A) the Department has initiated a notice of |
21 | | termination, suspension, or exclusion of the
vendor |
22 | | from participation in the medical assistance program; |
23 | | or
|
24 | | (B) the Department has issued notification of its |
25 | | withholding of
payments pursuant to subsection (F-5) |
26 | | of this Section; or
|
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1 | | (C) the Department has issued a notification of its |
2 | | withholding of
payments due to reliable evidence of |
3 | | fraud or willful misrepresentation
pending |
4 | | investigation.
|
5 | | (5) As used in this subsection, the following terms are |
6 | | defined as follows: |
7 | | (A) "Fraud" means an intentional deception or |
8 | | misrepresentation made by a person with the knowledge |
9 | | that the deception could result in some unauthorized |
10 | | benefit to himself or herself or some other person. It |
11 | | includes any act that constitutes fraud under |
12 | | applicable federal or State law. |
13 | | (B) "Abuse" means provider practices that are |
14 | | inconsistent with sound fiscal, business, or medical |
15 | | practices and that result in an unnecessary cost to the |
16 | | medical assistance program or in reimbursement for |
17 | | services that are not medically necessary or that fail |
18 | | to meet professionally recognized standards for health |
19 | | care. It also includes recipient practices that result |
20 | | in unnecessary cost to the medical assistance program. |
21 | | Abuse does not include diagnostic or therapeutic |
22 | | measures conducted primarily as a safeguard against |
23 | | possible vendor liability. |
24 | | (C) "Waste" means the unintentional misuse of |
25 | | medical assistance resources, resulting in unnecessary |
26 | | cost to the medical assistance program. Waste does not |
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1 | | include diagnostic or therapeutic measures conducted |
2 | | primarily as a safeguard against possible vendor |
3 | | liability. |
4 | | (D) "Harm" means physical, mental, or monetary |
5 | | damage to recipients or to the medical assistance |
6 | | program. |
7 | | (G-6) The Illinois Department, upon making a determination |
8 | | based upon information in the possession of the Illinois |
9 | | Department that continuation of participation in the medical |
10 | | assistance program by a vendor would constitute an immediate |
11 | | danger to the public, may immediately suspend such vendor's |
12 | | participation in the medical assistance program without a |
13 | | hearing. In instances in which the Illinois Department |
14 | | immediately suspends the medical assistance program |
15 | | participation of a vendor under this Section, a hearing upon |
16 | | the vendor's participation must be convened by the Illinois |
17 | | Department within 15 days after such suspension and completed |
18 | | without appreciable delay. Such hearing shall be held to |
19 | | determine whether to recommend to the Director that the |
20 | | vendor's medical assistance program participation be denied, |
21 | | terminated, suspended, placed on provisional status, or |
22 | | reinstated. In the hearing, any evidence relevant to the vendor |
23 | | constituting an immediate danger to the public may be |
24 | | introduced against such vendor; provided, however, that the |
25 | | vendor, or his or her counsel, shall have the opportunity to |
26 | | discredit, impeach, and submit evidence rebutting such |
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1 | | evidence. |
2 | | (H) Nothing contained in this Code shall in any way limit |
3 | | or
otherwise impair the authority or power of any State agency |
4 | | responsible
for licensing of vendors.
|
5 | | (I) Based on a finding of noncompliance on the part of a |
6 | | nursing home with
any requirement for certification under Title |
7 | | XVIII or XIX of the Social
Security Act (42 U.S.C. Sec. 1395 et |
8 | | seq. or 42 U.S.C. Sec. 1396 et seq.), the
Illinois Department |
9 | | may impose one or more of the following remedies after
notice |
10 | | to the facility:
|
11 | | (1) Termination of the provider agreement.
|
12 | | (2) Temporary management.
|
13 | | (3) Denial of payment for new admissions.
|
14 | | (4) Civil money penalties.
|
15 | | (5) Closure of the facility in emergency situations or |
16 | | transfer of
residents, or both.
|
17 | | (6) State monitoring.
|
18 | | (7) Denial of all payments when the U.S. Department of |
19 | | Health and Human Services has
imposed this sanction.
|
20 | | The Illinois Department shall by rule establish criteria |
21 | | governing continued
payments to a nursing facility subsequent |
22 | | to termination of the facility's
provider agreement if, in the |
23 | | sole discretion of the Illinois Department,
circumstances |
24 | | affecting the health, safety, and welfare of the facility's
|
25 | | residents require those continued payments. The Illinois |
26 | | Department may
condition those continued payments on the |
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1 | | appointment of temporary management,
sale of the facility to |
2 | | new owners or operators, or other
arrangements that the |
3 | | Illinois Department determines best serve the needs of
the |
4 | | facility's residents.
|
5 | | Except in the case of a facility that has a right to a |
6 | | hearing on the finding
of noncompliance before an agency of the |
7 | | federal government, a facility may
request a hearing before a |
8 | | State agency on any finding of noncompliance within
60 days |
9 | | after the notice of the intent to impose a remedy. Except in |
10 | | the case
of civil money penalties, a request for a hearing |
11 | | shall not delay imposition of
the penalty. The choice of |
12 | | remedies is not appealable at a hearing. The level
of |
13 | | noncompliance may be challenged only in the case of a civil |
14 | | money penalty.
The Illinois Department shall provide by rule |
15 | | for the State agency that will
conduct the evidentiary |
16 | | hearings.
|
17 | | The Illinois Department may collect interest on unpaid |
18 | | civil money penalties.
|
19 | | The Illinois Department may adopt all rules necessary to |
20 | | implement this
subsection (I).
|
21 | | (J) The Illinois Department, by rule, may permit individual |
22 | | practitioners to designate that Department payments that may be |
23 | | due the practitioner be made to an alternate payee or alternate |
24 | | payees. |
25 | | (a) Such alternate payee or alternate payees shall be |
26 | | required to register as an alternate payee in the Medical |
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1 | | Assistance Program with the Illinois Department. |
2 | | (b) If a practitioner designates an alternate payee, |
3 | | the alternate payee and practitioner shall be jointly and |
4 | | severally liable to the Department for payments made to the |
5 | | alternate payee. Pursuant to subsection (E) of this |
6 | | Section, any Department action to suspend or deny payment |
7 | | or recover money or overpayments from an alternate payee |
8 | | shall be subject to an administrative hearing. |
9 | | (c) Registration as an alternate payee or alternate |
10 | | payees in the Illinois Medical Assistance Program shall be |
11 | | conditional. At any time, the Illinois Department may deny |
12 | | or cancel any alternate payee's registration in the |
13 | | Illinois Medical Assistance Program without cause. Any |
14 | | such denial or cancellation is not subject to an |
15 | | administrative hearing. |
16 | | (d) The Illinois Department may seek a revocation of |
17 | | any alternate payee, and all owners, officers, and |
18 | | individuals with management responsibility for such |
19 | | alternate payee shall be permanently prohibited from |
20 | | participating as an owner, an officer, or an individual |
21 | | with management responsibility with an alternate payee in |
22 | | the Illinois Medical Assistance Program, if after |
23 | | reasonable notice and opportunity for a hearing the |
24 | | Illinois Department finds that: |
25 | | (1) the alternate payee is not complying with the |
26 | | Department's policy or rules and regulations, or with |
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1 | | the terms and conditions prescribed by the Illinois |
2 | | Department in its alternate payee registration |
3 | | agreement; or |
4 | | (2) the alternate payee has failed to keep or make |
5 | | available for inspection, audit, or copying, after |
6 | | receiving a written request from the Illinois |
7 | | Department, such records regarding payments claimed as |
8 | | an alternate payee; or |
9 | | (3) the alternate payee has failed to furnish any |
10 | | information requested by the Illinois Department |
11 | | regarding payments claimed as an alternate payee; or |
12 | | (4) the alternate payee has knowingly made, or |
13 | | caused to be made, any false statement or |
14 | | representation of a material fact in connection with |
15 | | the administration of the Illinois Medical Assistance |
16 | | Program; or |
17 | | (5) the alternate payee, a person with management |
18 | | responsibility for an alternate payee, an officer or |
19 | | person owning, either directly or indirectly, 5% or |
20 | | more of the shares of stock or other evidences of |
21 | | ownership in a corporate alternate payee, or a partner |
22 | | in a partnership which is an alternate payee: |
23 | | (a) was previously terminated, suspended, or |
24 | | excluded from participation as a vendor in the |
25 | | Illinois Medical Assistance Program, or was |
26 | | previously revoked as an alternate payee in the |
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1 | | Illinois Medical Assistance Program, or was |
2 | | terminated, suspended, or excluded from |
3 | | participation as a vendor in a medical assistance |
4 | | program in another state that is of the same kind |
5 | | as the program of medical assistance provided |
6 | | under Article V of this Code; or |
7 | | (b) was a person with management |
8 | | responsibility for a vendor previously terminated, |
9 | | suspended, or excluded from participation as a |
10 | | vendor in the Illinois Medical Assistance Program, |
11 | | or was previously revoked as an alternate payee in |
12 | | the Illinois Medical Assistance Program, or was |
13 | | terminated, suspended, or excluded from |
14 | | participation as a vendor in a medical assistance |
15 | | program in another state that is of the same kind |
16 | | as the program of medical assistance provided |
17 | | under Article V of this Code, during the time of |
18 | | conduct which was the basis for that vendor's |
19 | | termination, suspension, or exclusion or alternate |
20 | | payee's revocation; or |
21 | | (c) was an officer, or person owning, either |
22 | | directly or indirectly, 5% or more of the shares of |
23 | | stock or other evidences of ownership in a |
24 | | corporate vendor previously terminated, suspended, |
25 | | or excluded from participation as a vendor in the |
26 | | Illinois Medical Assistance Program, or was |
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1 | | previously revoked as an alternate payee in the |
2 | | Illinois Medical Assistance Program, or was |
3 | | terminated, suspended, or excluded from |
4 | | participation as a vendor in a medical assistance |
5 | | program in another state that is of the same kind |
6 | | as the program of medical assistance provided |
7 | | under Article V of this Code, during the time of |
8 | | conduct which was the basis for that vendor's |
9 | | termination, suspension, or exclusion; or |
10 | | (d) was an owner of a sole proprietorship or |
11 | | partner in a partnership previously terminated, |
12 | | suspended, or excluded from participation as a |
13 | | vendor in the Illinois Medical Assistance Program, |
14 | | or was previously revoked as an alternate payee in |
15 | | the Illinois Medical Assistance Program, or was |
16 | | terminated, suspended, or excluded from |
17 | | participation as a vendor in a medical assistance |
18 | | program in another state that is of the same kind |
19 | | as the program of medical assistance provided |
20 | | under Article V of this Code, during the time of |
21 | | conduct which was the basis for that vendor's |
22 | | termination, suspension, or exclusion or alternate |
23 | | payee's revocation; or |
24 | | (6) the alternate payee, a person with management |
25 | | responsibility for an alternate payee, an officer or |
26 | | person owning, either directly or indirectly, 5% or |
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1 | | more of the shares of stock or other evidences of |
2 | | ownership in a corporate alternate payee, or a partner |
3 | | in a partnership which is an alternate payee: |
4 | | (a) has engaged in conduct prohibited by |
5 | | applicable federal or State law or regulation |
6 | | relating to the Illinois Medical Assistance |
7 | | Program; or |
8 | | (b) was a person with management |
9 | | responsibility for a vendor or alternate payee at |
10 | | the time that the vendor or alternate payee engaged |
11 | | in practices prohibited by applicable federal or |
12 | | State law or regulation relating to the Illinois |
13 | | Medical Assistance Program; or |
14 | | (c) was an officer, or person owning, either |
15 | | directly or indirectly, 5% or more of the shares of |
16 | | stock or other evidences of ownership in a vendor |
17 | | or alternate payee at the time such vendor or |
18 | | alternate payee engaged in practices prohibited by |
19 | | applicable federal or State law or regulation |
20 | | relating to the Illinois Medical Assistance |
21 | | Program; or |
22 | | (d) was an owner of a sole proprietorship or |
23 | | partner in a partnership which was a vendor or |
24 | | alternate payee at the time such vendor or |
25 | | alternate payee engaged in practices prohibited by |
26 | | applicable federal or State law or regulation |
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1 | | relating to the Illinois Medical Assistance |
2 | | Program; or |
3 | | (7) the direct or indirect ownership of the vendor |
4 | | or alternate payee (including the ownership of a vendor |
5 | | or alternate payee that is a partner's interest in a |
6 | | vendor or alternate payee, or ownership of 5% or more |
7 | | of the shares of stock or other evidences of ownership |
8 | | in a corporate vendor or alternate payee) has been |
9 | | transferred by an individual who is terminated, |
10 | | suspended, or excluded or barred from participating as |
11 | | a vendor or is prohibited or revoked as an alternate |
12 | | payee to the individual's spouse, child, brother, |
13 | | sister, parent, grandparent, grandchild, uncle, aunt, |
14 | | niece, nephew, cousin, or relative by marriage. |
15 | | (K) The Illinois Department of Healthcare and Family |
16 | | Services may withhold payments, in whole or in part, to a |
17 | | provider or alternate payee where there is credible evidence, |
18 | | received from State or federal law enforcement or federal |
19 | | oversight agencies or from the results of a preliminary |
20 | | Department audit, that the circumstances giving rise to the |
21 | | need for a withholding of payments may involve fraud or willful |
22 | | misrepresentation under the Illinois Medical Assistance |
23 | | program. The Department shall by rule define what constitutes |
24 | | "credible" evidence for purposes of this subsection. The |
25 | | Department may withhold payments without first notifying the |
26 | | provider or alternate payee of its intention to withhold such |
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1 | | payments. A provider or alternate payee may request a |
2 | | reconsideration of payment withholding, and the Department |
3 | | must grant such a request. The Department shall state by rule a |
4 | | process and criteria by which a provider or alternate payee may |
5 | | request full or partial release of payments withheld under this |
6 | | subsection. This request may be made at any time after the |
7 | | Department first withholds such payments. |
8 | | (a) The Illinois Department must send notice of its
|
9 | | withholding of program payments within 5 days of taking |
10 | | such action. The notice must set forth the general |
11 | | allegations as to the nature of the withholding action, but |
12 | | need not disclose any specific information concerning its |
13 | | ongoing investigation. The notice must do all of the |
14 | | following: |
15 | | (1) State that payments are being withheld in
|
16 | | accordance with this subsection. |
17 | | (2) State that the withholding is for a temporary
|
18 | | period, as stated in paragraph (b) of this
subsection, |
19 | | and cite the circumstances under which
withholding |
20 | | will be terminated. |
21 | | (3) Specify, when appropriate, which type or types
|
22 | | of Medicaid claims withholding is effective. |
23 | | (4) Inform the provider or alternate payee of the
|
24 | | right to submit written evidence for reconsideration |
25 | | of the withholding by
the Illinois Department. |
26 | | (5) Inform the provider or alternate payee that a |
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1 | | written request may be made to the Illinois Department |
2 | | for full or partial release of withheld payments and |
3 | | that such requests may be made at any time after the |
4 | | Department first withholds such payments.
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5 | | (b) All withholding-of-payment actions under this
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6 | | subsection shall be temporary and shall not continue after |
7 | | any of the following: |
8 | | (1) The Illinois Department or the prosecuting
|
9 | | authorities determine that there is insufficient
|
10 | | evidence of fraud or willful misrepresentation by the
|
11 | | provider or alternate payee. |
12 | | (2) Legal proceedings related to the provider's or
|
13 | | alternate payee's alleged fraud, willful
|
14 | | misrepresentation, violations of this Act, or
|
15 | | violations of the Illinois Department's administrative
|
16 | | rules are completed. |
17 | | (3) The withholding of payments for a period of 3 |
18 | | years.
|
19 | | (c) The Illinois Department may adopt all rules |
20 | | necessary
to implement this subsection (K).
|
21 | | (K-5) The Illinois Department may withhold payments, in |
22 | | whole or in part, to a provider or alternate payee upon |
23 | | initiation of an audit, quality of care review, investigation |
24 | | when there is a credible allegation of fraud, or the provider |
25 | | or alternate payee demonstrating a clear failure to cooperate |
26 | | with the Illinois Department such that the circumstances give |
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1 | | rise to the need for a withholding of payments. As used in this |
2 | | subsection, "credible allegation" is defined to include an |
3 | | allegation from any source, including, but not limited to, |
4 | | fraud hotline complaints, claims data mining, patterns |
5 | | identified through provider audits, civil actions filed under |
6 | | the Illinois False Claims Act, and law enforcement |
7 | | investigations. An allegation is considered to be credible when |
8 | | it has indicia of reliability. The Illinois Department may |
9 | | withhold payments without first notifying the provider or |
10 | | alternate payee of its intention to withhold such payments. A |
11 | | provider or alternate payee may request a hearing or a |
12 | | reconsideration of payment withholding, and the Illinois |
13 | | Department must grant such a request. The Illinois Department |
14 | | shall state by rule a process and criteria by which a provider |
15 | | or alternate payee may request a hearing or a reconsideration |
16 | | for the full or partial release of payments withheld under this |
17 | | subsection. This request may be made at any time after the |
18 | | Illinois Department first withholds such payments. |
19 | | (a) The Illinois Department must send notice of its |
20 | | withholding of program payments within 5 days of taking |
21 | | such action. The notice must set forth the general |
22 | | allegations as to the nature of the withholding action but |
23 | | need not disclose any specific information concerning its |
24 | | ongoing investigation. The notice must do all of the |
25 | | following: |
26 | | (1) State that payments are being withheld in |
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1 | | accordance with this subsection. |
2 | | (2) State that the withholding is for a temporary |
3 | | period, as stated in paragraph (b) of this subsection, |
4 | | and cite the circumstances under which withholding |
5 | | will be terminated. |
6 | | (3) Specify, when appropriate, which type or types |
7 | | of claims are withheld. |
8 | | (4) Inform the provider or alternate payee of the |
9 | | right to request a hearing or a reconsideration of the |
10 | | withholding by the Illinois Department, including the |
11 | | ability to submit written evidence. |
12 | | (5) Inform the provider or alternate payee that a |
13 | | written request may be made to the Illinois Department |
14 | | for a hearing or a reconsideration for the full or |
15 | | partial release of withheld payments and that such |
16 | | requests may be made at any time after the Illinois |
17 | | Department first withholds such payments. |
18 | | (b) All withholding of payment actions under this |
19 | | subsection shall be temporary and shall not continue after |
20 | | any of the following: |
21 | | (1) The Illinois Department determines that there |
22 | | is insufficient evidence of fraud, or the provider or |
23 | | alternate payee demonstrates clear cooperation with |
24 | | the Illinois Department, as determined by the Illinois |
25 | | Department, such that the circumstances do not give |
26 | | rise to the need for withholding of payments; or |
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1 | | (2) The withholding of payments has lasted for a |
2 | | period in excess of 3 years. |
3 | | (c) The Illinois Department may adopt all rules |
4 | | necessary to implement this subsection (K-5). |
5 | | (L) The Illinois Department shall establish a protocol to |
6 | | enable health care providers to disclose an actual or potential |
7 | | violation of this Section pursuant to a self-referral |
8 | | disclosure protocol, referred to in this subsection as "the |
9 | | protocol". The protocol shall include direction for health care |
10 | | providers on a specific person, official, or office to whom |
11 | | such disclosures shall be made. The Illinois Department shall |
12 | | post information on the protocol on the Illinois Department's |
13 | | public website. The Illinois Department may adopt rules |
14 | | necessary to implement this subsection (L). In addition to |
15 | | other factors that the Illinois Department finds appropriate, |
16 | | the Illinois Department may consider a health care provider's |
17 | | timely use or failure to use the protocol in considering the |
18 | | provider's failure to comply with this Code. |
19 | | (M) Notwithstanding any other provision of this Code, the |
20 | | Illinois Department, at its discretion, may exempt an entity |
21 | | licensed under the Nursing Home Care Act and the ID/DD |
22 | | Community Care Act from the provisions of subsections (A-15), |
23 | | (B), and (C) of this Section if the licensed entity is in |
24 | | receivership. |
25 | | (Source: P.A. 97-689, eff. 6-14-12; 97-1150, eff. 1-25-13.)
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