Illinois General Assembly - Full Text of HB5539
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Full Text of HB5539  99th General Assembly

HB5539enr 99TH GENERAL ASSEMBLY

  
  
  

 


 
HB5539 EnrolledLRB099 19598 EGJ 43993 b

1    AN ACT concerning State government.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 12-4.25 as follows:
 
6    (305 ILCS 5/12-4.25)  (from Ch. 23, par. 12-4.25)
7    Sec. 12-4.25. Medical assistance program; vendor
8participation.
9    (A) The Illinois Department may deny, suspend, or terminate
10the eligibility of any person, firm, corporation, association,
11agency, institution or other legal entity to participate as a
12vendor of goods or services to recipients under the medical
13assistance program under Article V, or may exclude any such
14person or entity from participation as such a vendor, and may
15deny, suspend, or recover payments, if after reasonable notice
16and opportunity for a hearing the Illinois Department finds:
17        (a) Such vendor is not complying with the Department's
18    policy or rules and regulations, or with the terms and
19    conditions prescribed by the Illinois Department in its
20    vendor agreement, which document shall be developed by the
21    Department as a result of negotiations with each vendor
22    category, including physicians, hospitals, long term care
23    facilities, pharmacists, optometrists, podiatric

 

 

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1    physicians, and dentists setting forth the terms and
2    conditions applicable to the participation of each vendor
3    group in the program; or
4        (b) Such vendor has failed to keep or make available
5    for inspection, audit or copying, after receiving a written
6    request from the Illinois Department, such records
7    regarding payments claimed for providing services. This
8    section does not require vendors to make available patient
9    records of patients for whom services are not reimbursed
10    under this Code; or
11        (c) Such vendor has failed to furnish any information
12    requested by the Department regarding payments for
13    providing goods or services; or
14        (d) Such vendor has knowingly made, or caused to be
15    made, any false statement or representation of a material
16    fact in connection with the administration of the medical
17    assistance program; or
18        (e) Such vendor has furnished goods or services to a
19    recipient which are (1) in excess of need, (2) harmful, or
20    (3) of grossly inferior quality, all of such determinations
21    to be based upon competent medical judgment and
22    evaluations; or
23        (f) The vendor; a person with management
24    responsibility for a vendor; an officer or person owning,
25    either directly or indirectly, 5% or more of the shares of
26    stock or other evidences of ownership in a corporate

 

 

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1    vendor; an owner of a sole proprietorship which is a
2    vendor; or a partner in a partnership which is a vendor,
3    either:
4            (1) was previously terminated, suspended, or
5        excluded from participation in the Illinois medical
6        assistance program, or was terminated, suspended, or
7        excluded from participation in another state or
8        federal medical assistance or health care program; or
9            (2) was a person with management responsibility
10        for a vendor previously terminated, suspended, or
11        excluded from participation in the Illinois medical
12        assistance program, or terminated, suspended, or
13        excluded from participation in another state or
14        federal medical assistance or health care program
15        during the time of conduct which was the basis for that
16        vendor's termination, suspension, or exclusion; or
17            (3) was an officer, or person owning, either
18        directly or indirectly, 5% or more of the shares of
19        stock or other evidences of ownership in a corporate or
20        limited liability company vendor previously
21        terminated, suspended, or excluded from participation
22        in the Illinois medical assistance program, or
23        terminated, suspended, or excluded from participation
24        in a state or federal medical assistance or health care
25        program during the time of conduct which was the basis
26        for that vendor's termination, suspension, or

 

 

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1        exclusion; or
2            (4) was an owner of a sole proprietorship or
3        partner of a partnership previously terminated,
4        suspended, or excluded from participation in the
5        Illinois medical assistance program, or terminated,
6        suspended, or excluded from participation in a state or
7        federal medical assistance or health care program
8        during the time of conduct which was the basis for that
9        vendor's termination, suspension, or exclusion; or
10        (f-1) Such vendor has a delinquent debt owed to the
11    Illinois Department; or
12        (g) The vendor; a person with management
13    responsibility for a vendor; an officer or person owning,
14    either directly or indirectly, 5% or more of the shares of
15    stock or other evidences of ownership in a corporate or
16    limited liability company vendor; an owner of a sole
17    proprietorship which is a vendor; or a partner in a
18    partnership which is a vendor, either:
19            (1) has engaged in practices prohibited by
20        applicable federal or State law or regulation; or
21            (2) was a person with management responsibility
22        for a vendor at the time that such vendor engaged in
23        practices prohibited by applicable federal or State
24        law or regulation; or
25            (3) was an officer, or person owning, either
26        directly or indirectly, 5% or more of the shares of

 

 

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1        stock or other evidences of ownership in a vendor at
2        the time such vendor engaged in practices prohibited by
3        applicable federal or State law or regulation; or
4            (4) was an owner of a sole proprietorship or
5        partner of a partnership which was a vendor at the time
6        such vendor engaged in practices prohibited by
7        applicable federal or State law or regulation; or
8        (h) The direct or indirect ownership of the vendor
9    (including the ownership of a vendor that is a sole
10    proprietorship, a partner's interest in a vendor that is a
11    partnership, or ownership of 5% or more of the shares of
12    stock or other evidences of ownership in a corporate
13    vendor) has been transferred by an individual who is
14    terminated, suspended, or excluded or barred from
15    participating as a vendor to the individual's spouse,
16    child, brother, sister, parent, grandparent, grandchild,
17    uncle, aunt, niece, nephew, cousin, or relative by
18    marriage.
19    (A-5) The Illinois Department may deny, suspend, or
20terminate the eligibility of any person, firm, corporation,
21association, agency, institution, or other legal entity to
22participate as a vendor of goods or services to recipients
23under the medical assistance program under Article V, or may
24exclude any such person or entity from participation as such a
25vendor, if, after reasonable notice and opportunity for a
26hearing, the Illinois Department finds that the vendor; a

 

 

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1person with management responsibility for a vendor; an officer
2or person owning, either directly or indirectly, 5% or more of
3the shares of stock or other evidences of ownership in a
4corporate vendor; an owner of a sole proprietorship that is a
5vendor; or a partner in a partnership that is a vendor has been
6convicted of an offense based on fraud or willful
7misrepresentation related to any of the following:
8        (1) The medical assistance program under Article V of
9    this Code.
10        (2) A medical assistance or health care program in
11    another state.
12        (3) The Medicare program under Title XVIII of the
13    Social Security Act.
14        (4) The provision of health care services.
15        (5) A violation of this Code, as provided in Article
16    VIIIA, or another state or federal medical assistance
17    program or health care program.
18    (A-10) The Illinois Department may deny, suspend, or
19terminate the eligibility of any person, firm, corporation,
20association, agency, institution, or other legal entity to
21participate as a vendor of goods or services to recipients
22under the medical assistance program under Article V, or may
23exclude any such person or entity from participation as such a
24vendor, if, after reasonable notice and opportunity for a
25hearing, the Illinois Department finds that (i) the vendor,
26(ii) a person with management responsibility for a vendor,

 

 

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1(iii) an officer or person owning, either directly or
2indirectly, 5% or more of the shares of stock or other
3evidences of ownership in a corporate vendor, (iv) an owner of
4a sole proprietorship that is a vendor, or (v) a partner in a
5partnership that is a vendor has been convicted of an offense
6related to any of the following:
7        (1) Murder.
8        (2) A Class X felony under the Criminal Code of 1961 or
9    the Criminal Code of 2012.
10        (3) Sexual misconduct that may subject recipients to an
11    undue risk of harm.
12        (4) A criminal offense that may subject recipients to
13    an undue risk of harm.
14        (5) A crime of fraud or dishonesty.
15        (6) A crime involving a controlled substance.
16        (7) A misdemeanor relating to fraud, theft,
17    embezzlement, breach of fiduciary responsibility, or other
18    financial misconduct related to a health care program.
19    (A-15) The Illinois Department may deny the eligibility of
20any person, firm, corporation, association, agency,
21institution, or other legal entity to participate as a vendor
22of goods or services to recipients under the medical assistance
23program under Article V if, after reasonable notice and
24opportunity for a hearing, the Illinois Department finds:
25        (1) The applicant or any person with management
26    responsibility for the applicant; an officer or member of

 

 

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1    the board of directors of an applicant; an entity owning
2    (directly or indirectly) 5% or more of the shares of stock
3    or other evidences of ownership in a corporate vendor
4    applicant; an owner of a sole proprietorship applicant; a
5    partner in a partnership applicant; or a technical or other
6    advisor to an applicant has a debt owed to the Illinois
7    Department, and no payment arrangements acceptable to the
8    Illinois Department have been made by the applicant.
9        (2) The applicant or any person with management
10    responsibility for the applicant; an officer or member of
11    the board of directors of an applicant; an entity owning
12    (directly or indirectly) 5% or more of the shares of stock
13    or other evidences of ownership in a corporate vendor
14    applicant; an owner of a sole proprietorship applicant; a
15    partner in a partnership vendor applicant; or a technical
16    or other advisor to an applicant was (i) a person with
17    management responsibility, (ii) an officer or member of the
18    board of directors of an applicant, (iii) 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, (iv)
21    an owner of a sole proprietorship, (v) a partner in a
22    partnership vendor, (vi) a technical or other advisor to a
23    vendor, during a period of time where the conduct of that
24    vendor resulted in a debt owed to the Illinois Department,
25    and no payment arrangements acceptable to the Illinois
26    Department have been made by that vendor.

 

 

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1        (3) There is a credible allegation of the use,
2    transfer, or lease of assets of any kind to an applicant
3    from a current or prior vendor who has a debt owed to the
4    Illinois Department, no payment arrangements acceptable to
5    the Illinois Department have been made by that vendor or
6    the vendor's alternate payee, and the applicant knows or
7    should have known of such debt.
8        (4) There is a credible allegation of a transfer of
9    management responsibilities, or direct or indirect
10    ownership, to an applicant from a current or prior vendor
11    who has a debt owed to the Illinois Department, and no
12    payment arrangements acceptable to the Illinois Department
13    have been made by that vendor or the vendor's alternate
14    payee, and the applicant knows or should have known of such
15    debt.
16        (5) There is a credible allegation of the use,
17    transfer, or lease of assets of any kind to an applicant
18    who is a spouse, child, brother, sister, parent,
19    grandparent, grandchild, uncle, aunt, niece, relative by
20    marriage, nephew, cousin, or relative of a current or prior
21    vendor who has a debt owed to the Illinois Department and
22    no payment arrangements acceptable to the Illinois
23    Department have been made.
24        (6) There is a credible allegation that the applicant's
25    previous affiliations with a provider of medical services
26    that has an uncollected debt, a provider that has been or

 

 

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1    is subject to a payment suspension under a federal health
2    care program, or a provider that has been previously
3    excluded from participation in the medical assistance
4    program, poses a risk of fraud, waste, or abuse to the
5    Illinois Department.
6    As used in this subsection, "credible allegation" is
7defined to include an allegation from any source, including,
8but not limited to, fraud hotline complaints, claims data
9mining, patterns identified through provider audits, civil
10actions filed under the Illinois False Claims Act, and law
11enforcement investigations. An allegation is considered to be
12credible when it has indicia of reliability.
13    (B) The Illinois Department shall deny, suspend or
14terminate the eligibility of any person, firm, corporation,
15association, agency, institution or other legal entity to
16participate as a vendor of goods or services to recipients
17under the medical assistance program under Article V, or may
18exclude any such person or entity from participation as such a
19vendor:
20        (1) immediately, if such vendor is not properly
21    licensed, certified, or authorized;
22        (2) within 30 days of the date when such vendor's
23    professional license, certification or other authorization
24    has been refused renewal, restricted, revoked, suspended,
25    or otherwise terminated; or
26        (3) if such vendor has been convicted of a violation of

 

 

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1    this Code, as provided in Article VIIIA.
2    (C) Upon termination, suspension, or exclusion of a vendor
3of goods or services from participation in the medical
4assistance program authorized by this Article, a person with
5management responsibility for such vendor during the time of
6any conduct which served as the basis for that vendor's
7termination, suspension, or exclusion is barred from
8participation in the medical assistance program.
9    Upon termination, suspension, or exclusion of a corporate
10vendor, the officers and persons owning, directly or
11indirectly, 5% or more of the shares of stock or other
12evidences of ownership in the vendor during the time of any
13conduct which served as the basis for that vendor's
14termination, suspension, or exclusion are barred from
15participation in the medical assistance program. A person who
16owns, directly or indirectly, 5% or more of the shares of stock
17or other evidences of ownership in a terminated, suspended, or
18excluded vendor may not transfer his or her ownership interest
19in that vendor to his or her spouse, child, brother, sister,
20parent, grandparent, grandchild, uncle, aunt, niece, nephew,
21cousin, or relative by marriage.
22    Upon termination, suspension, or exclusion of a sole
23proprietorship or partnership, the owner or partners during the
24time of any conduct which served as the basis for that vendor's
25termination, suspension, or exclusion are barred from
26participation in the medical assistance program. The owner of a

 

 

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1terminated, suspended, or excluded vendor that is a sole
2proprietorship, and a partner in a terminated, suspended, or
3excluded vendor that is a partnership, may not transfer his or
4her ownership or partnership interest in that vendor to his or
5her spouse, child, brother, sister, parent, grandparent,
6grandchild, uncle, aunt, niece, nephew, cousin, or relative by
7marriage.
8    A person who owns, directly or indirectly, 5% or more of
9the shares of stock or other evidences of ownership in a
10corporate or limited liability company vendor who owes a debt
11to the Department, if that vendor has not made payment
12arrangements acceptable to the Department, shall not transfer
13his or her ownership interest in that vendor, or vendor assets
14of any kind, to his or her spouse, child, brother, sister,
15parent, grandparent, grandchild, uncle, aunt, niece, nephew,
16cousin, or relative by marriage.
17    Rules adopted by the Illinois Department to implement these
18provisions shall specifically include a definition of the term
19"management responsibility" as used in this Section. Such
20definition shall include, but not be limited to, typical job
21titles, and duties and descriptions which will be considered as
22within the definition of individuals with management
23responsibility for a provider.
24    A vendor or a prior vendor who has been terminated,
25excluded, or suspended from the medical assistance program, or
26from another state or federal medical assistance or health care

 

 

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1program, and any individual currently or previously barred from
2the medical assistance program, or from another state or
3federal medical assistance or health care program, as a result
4of being an officer or a person owning, directly or indirectly,
55% or more of the shares of stock or other evidences of
6ownership in a corporate or limited liability company vendor
7during the time of any conduct which served as the basis for
8that vendor's termination, suspension, or exclusion, may be
9required to post a surety bond as part of a condition of
10enrollment or participation in the medical assistance program.
11The Illinois Department shall establish, by rule, the criteria
12and requirements for determining when a surety bond must be
13posted and the value of the bond.
14    A vendor or a prior vendor who has a debt owed to the
15Illinois Department and any individual currently or previously
16barred from the medical assistance program, or from another
17state or federal medical assistance or health care program, as
18a result of being an officer or a person owning, directly or
19indirectly, 5% or more of the shares of stock or other
20evidences of ownership in that corporate or limited liability
21company vendor during the time of any conduct which served as
22the basis for the debt, may be required to post a surety bond
23as part of a condition of enrollment or participation in the
24medical assistance program. The Illinois Department shall
25establish, by rule, the criteria and requirements for
26determining when a surety bond must be posted and the value of

 

 

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1the bond.
2    (D) If a vendor has been suspended from the medical
3assistance program under Article V of the Code, the Director
4may require that such vendor correct any deficiencies which
5served as the basis for the suspension. The Director shall
6specify in the suspension order a specific period of time,
7which shall not exceed one year from the date of the order,
8during which a suspended vendor shall not be eligible to
9participate. At the conclusion of the period of suspension the
10Director shall reinstate such vendor, unless he finds that such
11vendor has not corrected deficiencies upon which the suspension
12was based.
13    If a vendor has been terminated, suspended, or excluded
14from the medical assistance program under Article V, such
15vendor shall be barred from participation for at least one
16year, except that if a vendor has been terminated, suspended,
17or excluded based on a conviction of a violation of Article
18VIIIA or a conviction of a felony based on fraud or a willful
19misrepresentation related to (i) the medical assistance
20program under Article V, (ii) a federal or another state's
21medical assistance or health care program, or (iii) the
22provision of health care services, then the vendor shall be
23barred from participation for 5 years or for the length of the
24vendor's sentence for that conviction, whichever is longer. At
25the end of one year a vendor who has been terminated,
26suspended, or excluded may apply for reinstatement to the

 

 

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1program. Upon proper application to be reinstated such vendor
2may be deemed eligible by the Director providing that such
3vendor meets the requirements for eligibility under this Code.
4If such vendor is deemed not eligible for reinstatement, he
5shall be barred from again applying for reinstatement for one
6year from the date his application for reinstatement is denied.
7    A vendor whose termination, suspension, or exclusion from
8participation in the Illinois medical assistance program under
9Article V was based solely on an action by a governmental
10entity other than the Illinois Department may, upon
11reinstatement by that governmental entity or upon reversal of
12the termination, suspension, or exclusion, apply for
13rescission of the termination, suspension, or exclusion from
14participation in the Illinois medical assistance program. Upon
15proper application for rescission, the vendor may be deemed
16eligible by the Director if the vendor meets the requirements
17for eligibility under this Code.
18    If a vendor has been terminated, suspended, or excluded and
19reinstated to the medical assistance program under Article V
20and the vendor is terminated, suspended, or excluded a second
21or subsequent time from the medical assistance program, the
22vendor shall be barred from participation for at least 2 years,
23except that if a vendor has been terminated, suspended, or
24excluded a second time based on a conviction of a violation of
25Article VIIIA or a conviction of a felony based on fraud or a
26willful misrepresentation related to (i) the medical

 

 

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1assistance program under Article V, (ii) a federal or another
2state's medical assistance or health care program, or (iii) the
3provision of health care services, then the vendor shall be
4barred from participation for life. At the end of 2 years, a
5vendor who has been terminated, suspended, or excluded may
6apply for reinstatement to the program. Upon application to be
7reinstated, the vendor may be deemed eligible if the vendor
8meets the requirements for eligibility under this Code. If the
9vendor is deemed not eligible for reinstatement, the vendor
10shall be barred from again applying for reinstatement for 2
11years from the date the vendor's application for reinstatement
12is denied.
13    (E) The Illinois Department may recover money improperly or
14erroneously paid, or overpayments, either by setoff, crediting
15against future billings or by requiring direct repayment to the
16Illinois Department. The Illinois Department may suspend or
17deny payment, in whole or in part, if such payment would be
18improper or erroneous or would otherwise result in overpayment.
19        (1) Payments may be suspended, denied, or recovered
20    from a vendor or alternate payee: (i) for services rendered
21    in violation of the Illinois Department's provider
22    notices, statutes, rules, and regulations; (ii) for
23    services rendered in violation of the terms and conditions
24    prescribed by the Illinois Department in its vendor
25    agreement; (iii) for any vendor who fails to grant the
26    Office of Inspector General timely access to full and

 

 

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1    complete records, including, but not limited to, records
2    relating to recipients under the medical assistance
3    program for the most recent 6 years, in accordance with
4    Section 140.28 of Title 89 of the Illinois Administrative
5    Code, and other information for the purpose of audits,
6    investigations, or other program integrity functions,
7    after reasonable written request by the Inspector General;
8    this subsection (E) does not require vendors to make
9    available the medical records of patients for whom services
10    are not reimbursed under this Code or to provide access to
11    medical records more than 6 years old; (iv) when the vendor
12    has knowingly made, or caused to be made, any false
13    statement or representation of a material fact in
14    connection with the administration of the medical
15    assistance program; or (v) when the vendor previously
16    rendered services while terminated, suspended, or excluded
17    from participation in the medical assistance program or
18    while terminated or excluded from participation in another
19    state or federal medical assistance or health care program.
20    Notwithstanding any other provision to the contrary, the
21    Department shall not seek recovery of overpayments,
22    adjustments, or other amounts due that are more than 6
23    years old, except in the following circumstances: (i) there
24    is an active investigation initiated by the Department of
25    State Police or any other State or federal law enforcement
26    agency during the 6-year period, in which case the 6-year

 

 

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1    limitation for the recovery of overpayments, adjustments,
2    or other amounts due is tolled for the period of time the
3    matter is under investigation or prosecution; or (ii) the
4    Centers for Medicare and Medicaid Services attempts to
5    recover federal financial participation moneys from the
6    Department resulting from an overpayment more than 6 years
7    old and the Centers for Medicare and Medicaid Services
8    determines that the overpayment is not discharged or
9    uncollectible pursuant to Section 1903(d)(2)(D) of the
10    Social Security Act.
11        (2) Notwithstanding any other provision of law, if a
12    vendor has the same taxpayer identification number
13    (assigned under Section 6109 of the Internal Revenue Code
14    of 1986) as is assigned to a vendor with past-due financial
15    obligations to the Illinois Department, the Illinois
16    Department may make any necessary adjustments to payments
17    to that vendor in order to satisfy any past-due
18    obligations, regardless of whether the vendor is assigned a
19    different billing number under the medical assistance
20    program.
21    (E-5) Civil monetary penalties.
22        (1) As used in this subsection (E-5):
23            (a) "Knowingly" means that a person, with respect
24        to information: (i) has actual knowledge of the
25        information; (ii) acts in deliberate ignorance of the
26        truth or falsity of the information; or (iii) acts in

 

 

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1        reckless disregard of the truth or falsity of the
2        information. No proof of specific intent to defraud is
3        required.
4            (b) "Overpayment" means any funds that a person
5        receives or retains from the medical assistance
6        program to which the person, after applicable
7        reconciliation, is not entitled under this Code.
8            (c) "Remuneration" means the offer or transfer of
9        items or services for free or for other than fair
10        market value by a person; however, remuneration does
11        not include items or services of a nominal value of no
12        more than $10 per item or service, or $50 in the
13        aggregate on an annual basis, or any other offer or
14        transfer of items or services as determined by the
15        Department.
16            (d) "Should know" means that a person, with respect
17        to information: (i) acts in deliberate ignorance of the
18        truth or falsity of the information; or (ii) acts in
19        reckless disregard of the truth or falsity of the
20        information. No proof of specific intent to defraud is
21        required.
22        (2) Any person (including a vendor, provider,
23    organization, agency, or other entity, or an alternate
24    payee thereof, but excluding a recipient) who:
25            (a) knowingly presents or causes to be presented to
26        an officer, employee, or agent of the State, a claim

 

 

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1        that the Department determines:
2                (i) is for a medical or other item or service
3            that the person knows or should know was not
4            provided as claimed, including any person who
5            engages in a pattern or practice of presenting or
6            causing to be presented a claim for an item or
7            service that is based on a code that the person
8            knows or should know will result in a greater
9            payment to the person than the code the person
10            knows or should know is applicable to the item or
11            service actually provided;
12                (ii) is for a medical or other item or service
13            and the person knows or should know that the claim
14            is false or fraudulent;
15                (iii) is presented for a vendor physician's
16            service, or an item or service incident to a vendor
17            physician's service, by a person who knows or
18            should know that the individual who furnished, or
19            supervised the furnishing of, the service:
20                    (AA) was not licensed as a physician;
21                    (BB) was licensed as a physician but such
22                license had been obtained through a
23                misrepresentation of material fact (including
24                cheating on an examination required for
25                licensing); or
26                    (CC) represented to the patient at the

 

 

HB5539 Enrolled- 21 -LRB099 19598 EGJ 43993 b

1                time the service was furnished that the
2                physician was certified in a medical specialty
3                by a medical specialty board, when the
4                individual was not so certified;
5                (iv) is for a medical or other item or service
6            furnished during a period in which the person was
7            excluded from the medical assistance program or a
8            federal or state health care program under which
9            the claim was made pursuant to applicable law; or
10                (v) is for a pattern of medical or other items
11            or services that a person knows or should know are
12            not medically necessary;
13            (b) knowingly presents or causes to be presented to
14        any person a request for payment which is in violation
15        of the conditions for receipt of vendor payments under
16        the medical assistance program under Section 11-13 of
17        this Code;
18            (c) knowingly gives or causes to be given to any
19        person, with respect to medical assistance program
20        coverage of inpatient hospital services, information
21        that he or she knows or should know is false or
22        misleading, and that could reasonably be expected to
23        influence the decision when to discharge such person or
24        other individual from the hospital;
25            (d) in the case of a person who is not an
26        organization, agency, or other entity, is excluded

 

 

HB5539 Enrolled- 22 -LRB099 19598 EGJ 43993 b

1        from participating in the medical assistance program
2        or a federal or state health care program and who, at
3        the time of a violation of this subsection (E-5):
4                (i) retains a direct or indirect ownership or
5            control interest in an entity that is
6            participating in the medical assistance program or
7            a federal or state health care program, and who
8            knows or should know of the action constituting the
9            basis for the exclusion; or
10                (ii) is an officer or managing employee of such
11            an entity;
12            (e) offers or transfers remuneration to any
13        individual eligible for benefits under the medical
14        assistance program that such person knows or should
15        know is likely to influence such individual to order or
16        receive from a particular vendor, provider,
17        practitioner, or supplier any item or service for which
18        payment may be made, in whole or in part, under the
19        medical assistance program;
20            (f) arranges or contracts (by employment or
21        otherwise) with an individual or entity that the person
22        knows or should know is excluded from participation in
23        the medical assistance program or a federal or state
24        health care program, for the provision of items or
25        services for which payment may be made under such a
26        program;

 

 

HB5539 Enrolled- 23 -LRB099 19598 EGJ 43993 b

1            (g) commits an act described in subsection (b) or
2        (c) of Section 8A-3;
3            (h) knowingly makes, uses, or causes to be made or
4        used, a false record or statement material to a false
5        or fraudulent claim for payment for items and services
6        furnished under the medical assistance program;
7            (i) fails to grant timely access, upon reasonable
8        request (as defined by the Department by rule), to the
9        Inspector General, for the purpose of audits,
10        investigations, evaluations, or other statutory
11        functions of the Inspector General of the Department;
12            (j) orders or prescribes a medical or other item or
13        service during a period in which the person was
14        excluded from the medical assistance program or a
15        federal or state health care program, in the case where
16        the person knows or should know that a claim for such
17        medical or other item or service will be made under
18        such a program;
19            (k) knowingly makes or causes to be made any false
20        statement, omission, or misrepresentation of a
21        material fact in any application, bid, or contract to
22        participate or enroll as a vendor or provider of
23        services or a supplier under the medical assistance
24        program;
25            (l) knows of an overpayment and does not report and
26        return the overpayment to the Department in accordance

 

 

HB5539 Enrolled- 24 -LRB099 19598 EGJ 43993 b

1        with paragraph (6);
2    shall be subject, in addition to any other penalties that
3    may be prescribed by law, to a civil money penalty of not
4    more than $10,000 for each item or service (or, in cases
5    under subparagraph (c), $15,000 for each individual with
6    respect to whom false or misleading information was given;
7    in cases under subparagraph (d), $10,000 for each day the
8    prohibited relationship occurs; in cases under
9    subparagraph (g), $50,000 for each such act; in cases under
10    subparagraph (h), $50,000 for each false record or
11    statement; in cases under subparagraph (i), $15,000 for
12    each day of the failure described in such subparagraph; or
13    in cases under subparagraph (k), $50,000 for each false
14    statement, omission, or misrepresentation of a material
15    fact). In addition, such a person shall be subject to an
16    assessment of not more than 3 times the amount claimed for
17    each such item or service in lieu of damages sustained by
18    the State because of such claim (or, in cases under
19    subparagraph (g), damages of not more than 3 times the
20    total amount of remuneration offered, paid, solicited, or
21    received, without regard to whether a portion of such
22    remuneration was offered, paid, solicited, or received for
23    a lawful purpose; or in cases under subparagraph (k), an
24    assessment of not more than 3 times the total amount
25    claimed for each item or service for which payment was made
26    based upon the application, bid, or contract containing the

 

 

HB5539 Enrolled- 25 -LRB099 19598 EGJ 43993 b

1    false statement, omission, or misrepresentation of a
2    material fact).
3        (3) In addition, the Director or his or her designee
4    may make a determination in the same proceeding to exclude,
5    terminate, suspend, or bar the person from participation in
6    the medical assistance program.
7        (4) The Illinois Department may seek the civil monetary
8    penalties and exclusion, termination, suspension, or
9    barment identified in this subsection (E-5). Prior to the
10    imposition of any penalties or sanctions, the affected
11    person shall be afforded an opportunity for a hearing after
12    reasonable notice. The Department shall establish hearing
13    procedures by rule.
14        (5) Any final order, decision, or other determination
15    made, issued, or executed by the Director under the
16    provisions of this subsection (E-5), whereby a person is
17    aggrieved, shall be subject to review in accordance with
18    the provisions of the Administrative Review Law, and the
19    rules adopted pursuant thereto, which shall apply to and
20    govern all proceedings for the judicial review of final
21    administrative decisions of the Director.
22        (6)(a) If a person has received an overpayment, the
23    person shall:
24            (i) report and return the overpayment to the
25        Department at the correct address; and
26            (ii) notify the Department in writing of the reason

 

 

HB5539 Enrolled- 26 -LRB099 19598 EGJ 43993 b

1        for the overpayment.
2        (b) An overpayment must be reported and returned under
3    subparagraph (a) by the later of:
4            (i) the date which is 60 days after the date on
5        which the overpayment was identified; or
6            (ii) the date any corresponding cost report is due,
7        if applicable.
8    (E-10) A vendor who disputes an overpayment identified as
9part of a Department audit shall utilize the Department's
10self-referral disclosure protocol as set forth under this Code
11to identify, investigate, and return to the Department any
12undisputed audit overpayment amount. Unless the disputed
13overpayment amount is subject to a fraud payment suspension, or
14involves a termination sanction, the Department shall defer the
15recovery of the disputed overpayment amount up to one year
16after the date of the Department's final audit determination,
17or earlier, or as required by State or federal law. If the
18administrative hearing extends beyond one year, and such delay
19was not caused by the request of the vendor, then the
20Department shall not recover the disputed overpayment amount
21until the date of the final administrative decision. If a final
22administrative decision establishes that the disputed
23overpayment amount is owed to the Department, then the amount
24shall be immediately due to the Department. The Department
25shall be entitled to recover interest from the vendor on the
26overpayment amount from the date of the overpayment through the

 

 

HB5539 Enrolled- 27 -LRB099 19598 EGJ 43993 b

1date the vendor returns the overpayment to the Department at a
2rate not to exceed the Wall Street Journal Prime Rate, as
3published from time to time, but not to exceed 5%. Any interest
4billed by the Department shall be due immediately upon receipt
5of the Department's billing statement.
6    (F) The Illinois Department may withhold payments to any
7vendor or alternate payee prior to or during the pendency of
8any audit or proceeding under this Section, and through the
9pendency of any administrative appeal or administrative review
10by any court proceeding. The Illinois Department shall state by
11rule with as much specificity as practicable the conditions
12under which payments will not be withheld under this Section.
13Payments may be denied for bills submitted with service dates
14occurring during the pendency of a proceeding, after a final
15decision has been rendered, or after the conclusion of any
16administrative appeal, where the final administrative decision
17is to terminate, exclude, or suspend eligibility to participate
18in the medical assistance program. The Illinois Department
19shall state by rule with as much specificity as practicable the
20conditions under which payments will not be denied for such
21bills. The Illinois Department shall state by rule a process
22and criteria by which a vendor or alternate payee may request
23full or partial release of payments withheld under this
24subsection. The Department must complete a proceeding under
25this Section in a timely manner.
26    Notwithstanding recovery allowed under subsection (E) or

 

 

HB5539 Enrolled- 28 -LRB099 19598 EGJ 43993 b

1this subsection (F), the Illinois Department may withhold
2payments to any vendor or alternate payee who is not properly
3licensed, certified, or in compliance with State or federal
4agency regulations. Payments may be denied for bills submitted
5with service dates occurring during the period of time that a
6vendor is not properly licensed, certified, or in compliance
7with State or federal regulations. Facilities licensed under
8the Nursing Home Care Act shall have payments denied or
9withheld pursuant to subsection (I) of this Section.
10    (F-5) The Illinois Department may temporarily withhold
11payments to a vendor or alternate payee if any of the following
12individuals have been indicted or otherwise charged under a law
13of the United States or this or any other state with an offense
14that is based on alleged fraud or willful misrepresentation on
15the part of the individual related to (i) the medical
16assistance program under Article V of this Code, (ii) a federal
17or another state's medical assistance or health care program,
18or (iii) the provision of health care services:
19        (1) If the vendor or alternate payee is a corporation:
20    an officer of the corporation or an individual who owns,
21    either directly or indirectly, 5% or more of the shares of
22    stock or other evidence of ownership of the corporation.
23        (2) If the vendor is a sole proprietorship: the owner
24    of the sole proprietorship.
25        (3) If the vendor or alternate payee is a partnership:
26    a partner in the partnership.

 

 

HB5539 Enrolled- 29 -LRB099 19598 EGJ 43993 b

1        (4) If the vendor or alternate payee is any other
2    business entity authorized by law to transact business in
3    this State: an officer of the entity or an individual who
4    owns, either directly or indirectly, 5% or more of the
5    evidences of ownership of the entity.
6    If the Illinois Department withholds payments to a vendor
7or alternate payee under this subsection, the Department shall
8not release those payments to the vendor or alternate payee
9while any criminal proceeding related to the indictment or
10charge is pending unless the Department determines that there
11is good cause to release the payments before completion of the
12proceeding. If the indictment or charge results in the
13individual's conviction, the Illinois Department shall retain
14all withheld payments, which shall be considered forfeited to
15the Department. If the indictment or charge does not result in
16the individual's conviction, the Illinois Department shall
17release to the vendor or alternate payee all withheld payments.
18    (F-10) If the Illinois Department establishes that the
19vendor or alternate payee owes a debt to the Illinois
20Department, and the vendor or alternate payee subsequently
21fails to pay or make satisfactory payment arrangements with the
22Illinois Department for the debt owed, the Illinois Department
23may seek all remedies available under the law of this State to
24recover the debt, including, but not limited to, wage
25garnishment or the filing of claims or liens against the vendor
26or alternate payee.

 

 

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1    (F-15) Enforcement of judgment.
2        (1) Any fine, recovery amount, other sanction, or costs
3    imposed, or part of any fine, recovery amount, other
4    sanction, or cost imposed, remaining unpaid after the
5    exhaustion of or the failure to exhaust judicial review
6    procedures under the Illinois Administrative Review Law is
7    a debt due and owing the State and may be collected using
8    all remedies available under the law.
9        (2) After expiration of the period in which judicial
10    review under the Illinois Administrative Review Law may be
11    sought for a final administrative decision, unless stayed
12    by a court of competent jurisdiction, the findings,
13    decision, and order of the Director may be enforced in the
14    same manner as a judgment entered by a court of competent
15    jurisdiction.
16        (3) In any case in which any person or entity has
17    failed to comply with a judgment ordering or imposing any
18    fine or other sanction, any expenses incurred by the
19    Illinois Department to enforce the judgment, including,
20    but not limited to, attorney's fees, court costs, and costs
21    related to property demolition or foreclosure, after they
22    are fixed by a court of competent jurisdiction or the
23    Director, shall be a debt due and owing the State and may
24    be collected in accordance with applicable law. Prior to
25    any expenses being fixed by a final administrative decision
26    pursuant to this subsection (F-15), the Illinois

 

 

HB5539 Enrolled- 31 -LRB099 19598 EGJ 43993 b

1    Department shall provide notice to the individual or entity
2    that states that the individual or entity shall appear at a
3    hearing before the administrative hearing officer to
4    determine whether the individual or entity has failed to
5    comply with the judgment. The notice shall set the date for
6    such a hearing, which shall not be less than 7 days from
7    the date that notice is served. If notice is served by
8    mail, the 7-day period shall begin to run on the date that
9    the notice was deposited in the mail.
10        (4) Upon being recorded in the manner required by
11    Article XII of the Code of Civil Procedure or by the
12    Uniform Commercial Code, a lien shall be imposed on the
13    real estate or personal estate, or both, of the individual
14    or entity in the amount of any debt due and owing the State
15    under this Section. The lien may be enforced in the same
16    manner as a judgment of a court of competent jurisdiction.
17    A lien shall attach to all property and assets of such
18    person, firm, corporation, association, agency,
19    institution, or other legal entity until the judgment is
20    satisfied.
21        (5) The Director may set aside any judgment entered by
22    default and set a new hearing date upon a petition filed at
23    any time (i) if the petitioner's failure to appear at the
24    hearing was for good cause, or (ii) if the petitioner
25    established that the Department did not provide proper
26    service of process. If any judgment is set aside pursuant

 

 

HB5539 Enrolled- 32 -LRB099 19598 EGJ 43993 b

1    to this paragraph (5), the hearing officer shall have
2    authority to enter an order extinguishing any lien which
3    has been recorded for any debt due and owing the Illinois
4    Department as a result of the vacated default judgment.
5    (G) The provisions of the Administrative Review Law, as now
6or hereafter amended, and the rules adopted pursuant thereto,
7shall apply to and govern all proceedings for the judicial
8review of final administrative decisions of the Illinois
9Department under this Section. The term "administrative
10decision" is defined as in Section 3-101 of the Code of Civil
11Procedure.
12    (G-5) Vendors who pose a risk of fraud, waste, abuse, or
13harm.
14        (1) Notwithstanding any other provision in this
15    Section, the Department may terminate, suspend, or exclude
16    vendors who pose a risk of fraud, waste, abuse, or harm
17    from participation in the medical assistance program prior
18    to an evidentiary hearing but after reasonable notice and
19    opportunity to respond as established by the Department by
20    rule.
21        (2) Vendors who pose a risk of fraud, waste, abuse, or
22    harm shall submit to a fingerprint-based criminal
23    background check on current and future information
24    available in the State system and current information
25    available through the Federal Bureau of Investigation's
26    system by submitting all necessary fees and information in

 

 

HB5539 Enrolled- 33 -LRB099 19598 EGJ 43993 b

1    the form and manner prescribed by the Department of State
2    Police. The following individuals shall be subject to the
3    check:
4            (A) In the case of a vendor that is a corporation,
5        every shareholder who owns, directly or indirectly, 5%
6        or more of the outstanding shares of the corporation.
7            (B) In the case of a vendor that is a partnership,
8        every partner.
9            (C) In the case of a vendor that is a sole
10        proprietorship, the sole proprietor.
11            (D) Each officer or manager of the vendor.
12        Each such vendor shall be responsible for payment of
13    the cost of the criminal background check.
14        (3) Vendors who pose a risk of fraud, waste, abuse, or
15    harm may be required to post a surety bond. The Department
16    shall establish, by rule, the criteria and requirements for
17    determining when a surety bond must be posted and the value
18    of the bond.
19        (4) The Department, or its agents, may refuse to accept
20    requests for authorization from specific vendors who pose a
21    risk of fraud, waste, abuse, or harm, including
22    prior-approval and post-approval requests, if:
23            (A) the Department has initiated a notice of
24        termination, suspension, or exclusion of the vendor
25        from participation in the medical assistance program;
26        or

 

 

HB5539 Enrolled- 34 -LRB099 19598 EGJ 43993 b

1            (B) the Department has issued notification of its
2        withholding of payments pursuant to subsection (F-5)
3        of this Section; or
4            (C) the Department has issued a notification of its
5        withholding of payments due to reliable evidence of
6        fraud or willful misrepresentation pending
7        investigation.
8        (5) As used in this subsection, the following terms are
9    defined as follows:
10            (A) "Fraud" means an intentional deception or
11        misrepresentation made by a person with the knowledge
12        that the deception could result in some unauthorized
13        benefit to himself or herself or some other person. It
14        includes any act that constitutes fraud under
15        applicable federal or State law.
16            (B) "Abuse" means provider practices that are
17        inconsistent with sound fiscal, business, or medical
18        practices and that result in an unnecessary cost to the
19        medical assistance program or in reimbursement for
20        services that are not medically necessary or that fail
21        to meet professionally recognized standards for health
22        care. It also includes recipient practices that result
23        in unnecessary cost to the medical assistance program.
24        Abuse does not include diagnostic or therapeutic
25        measures conducted primarily as a safeguard against
26        possible vendor liability.

 

 

HB5539 Enrolled- 35 -LRB099 19598 EGJ 43993 b

1            (C) "Waste" means the unintentional misuse of
2        medical assistance resources, resulting in unnecessary
3        cost to the medical assistance program. Waste does not
4        include diagnostic or therapeutic measures conducted
5        primarily as a safeguard against possible vendor
6        liability.
7            (D) "Harm" means physical, mental, or monetary
8        damage to recipients or to the medical assistance
9        program.
10    (G-6) The Illinois Department, upon making a determination
11based upon information in the possession of the Illinois
12Department that continuation of participation in the medical
13assistance program by a vendor would constitute an immediate
14danger to the public, may immediately suspend such vendor's
15participation in the medical assistance program without a
16hearing. In instances in which the Illinois Department
17immediately suspends the medical assistance program
18participation of a vendor under this Section, a hearing upon
19the vendor's participation must be convened by the Illinois
20Department within 15 days after such suspension and completed
21without appreciable delay. Such hearing shall be held to
22determine whether to recommend to the Director that the
23vendor's medical assistance program participation be denied,
24terminated, suspended, placed on provisional status, or
25reinstated. In the hearing, any evidence relevant to the vendor
26constituting an immediate danger to the public may be

 

 

HB5539 Enrolled- 36 -LRB099 19598 EGJ 43993 b

1introduced against such vendor; provided, however, that the
2vendor, or his or her counsel, shall have the opportunity to
3discredit, impeach, and submit evidence rebutting such
4evidence.
5    (H) Nothing contained in this Code shall in any way limit
6or otherwise impair the authority or power of any State agency
7responsible for licensing of vendors.
8    (I) Based on a finding of noncompliance on the part of a
9nursing home with any requirement for certification under Title
10XVIII or XIX of the Social Security Act (42 U.S.C. Sec. 1395 et
11seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois Department
12may impose one or more of the following remedies after notice
13to the facility:
14        (1) Termination of the provider agreement.
15        (2) Temporary management.
16        (3) Denial of payment for new admissions.
17        (4) Civil money penalties.
18        (5) Closure of the facility in emergency situations or
19    transfer of residents, or both.
20        (6) State monitoring.
21        (7) Denial of all payments when the U.S. Department of
22    Health and Human Services has imposed this sanction.
23    The Illinois Department shall by rule establish criteria
24governing continued payments to a nursing facility subsequent
25to termination of the facility's provider agreement if, in the
26sole discretion of the Illinois Department, circumstances

 

 

HB5539 Enrolled- 37 -LRB099 19598 EGJ 43993 b

1affecting the health, safety, and welfare of the facility's
2residents require those continued payments. The Illinois
3Department may condition those continued payments on the
4appointment of temporary management, sale of the facility to
5new owners or operators, or other arrangements that the
6Illinois Department determines best serve the needs of the
7facility's residents.
8    Except in the case of a facility that has a right to a
9hearing on the finding of noncompliance before an agency of the
10federal government, a facility may request a hearing before a
11State agency on any finding of noncompliance within 60 days
12after the notice of the intent to impose a remedy. Except in
13the case of civil money penalties, a request for a hearing
14shall not delay imposition of the penalty. The choice of
15remedies is not appealable at a hearing. The level of
16noncompliance may be challenged only in the case of a civil
17money penalty. The Illinois Department shall provide by rule
18for the State agency that will conduct the evidentiary
19hearings.
20    The Illinois Department may collect interest on unpaid
21civil money penalties.
22    The Illinois Department may adopt all rules necessary to
23implement this subsection (I).
24    (J) The Illinois Department, by rule, may permit individual
25practitioners to designate that Department payments that may be
26due the practitioner be made to an alternate payee or alternate

 

 

HB5539 Enrolled- 38 -LRB099 19598 EGJ 43993 b

1payees.
2        (a) Such alternate payee or alternate payees shall be
3    required to register as an alternate payee in the Medical
4    Assistance Program with the Illinois Department.
5        (b) If a practitioner designates an alternate payee,
6    the alternate payee and practitioner shall be jointly and
7    severally liable to the Department for payments made to the
8    alternate payee. Pursuant to subsection (E) of this
9    Section, any Department action to suspend or deny payment
10    or recover money or overpayments from an alternate payee
11    shall be subject to an administrative hearing.
12        (c) Registration as an alternate payee or alternate
13    payees in the Illinois Medical Assistance Program shall be
14    conditional. At any time, the Illinois Department may deny
15    or cancel any alternate payee's registration in the
16    Illinois Medical Assistance Program without cause. Any
17    such denial or cancellation is not subject to an
18    administrative hearing.
19        (d) The Illinois Department may seek a revocation of
20    any alternate payee, and all owners, officers, and
21    individuals with management responsibility for such
22    alternate payee shall be permanently prohibited from
23    participating as an owner, an officer, or an individual
24    with management responsibility with an alternate payee in
25    the Illinois Medical Assistance Program, if after
26    reasonable notice and opportunity for a hearing the

 

 

HB5539 Enrolled- 39 -LRB099 19598 EGJ 43993 b

1    Illinois Department finds that:
2            (1) the alternate payee is not complying with the
3        Department's policy or rules and regulations, or with
4        the terms and conditions prescribed by the Illinois
5        Department in its alternate payee registration
6        agreement; or
7            (2) the alternate payee has failed to keep or make
8        available for inspection, audit, or copying, after
9        receiving a written request from the Illinois
10        Department, such records regarding payments claimed as
11        an alternate payee; or
12            (3) the alternate payee has failed to furnish any
13        information requested by the Illinois Department
14        regarding payments claimed as an alternate payee; or
15            (4) the alternate payee has knowingly made, or
16        caused to be made, any false statement or
17        representation of a material fact in connection with
18        the administration of the Illinois Medical Assistance
19        Program; or
20            (5) the alternate payee, a person with management
21        responsibility for an alternate payee, an officer or
22        person owning, either directly or indirectly, 5% or
23        more of the shares of stock or other evidences of
24        ownership in a corporate alternate payee, or a partner
25        in a partnership which is an alternate payee:
26                (a) was previously terminated, suspended, or

 

 

HB5539 Enrolled- 40 -LRB099 19598 EGJ 43993 b

1            excluded from participation as a vendor in the
2            Illinois Medical Assistance Program, or was
3            previously revoked as an alternate payee in the
4            Illinois Medical Assistance Program, or was
5            terminated, suspended, or excluded from
6            participation as a vendor in a medical assistance
7            program in another state that is of the same kind
8            as the program of medical assistance provided
9            under Article V of this Code; or
10                (b) was a person with management
11            responsibility for a vendor 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                (c) 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

 

 

HB5539 Enrolled- 41 -LRB099 19598 EGJ 43993 b

1            corporate vendor previously terminated, suspended,
2            or excluded from participation as a vendor in the
3            Illinois Medical Assistance Program, or was
4            previously revoked as an alternate payee in the
5            Illinois Medical Assistance Program, or was
6            terminated, suspended, or excluded from
7            participation as a vendor in a medical assistance
8            program in another state that is of the same kind
9            as the program of medical assistance provided
10            under Article V of this Code, during the time of
11            conduct which was the basis for that vendor's
12            termination, suspension, or exclusion; or
13                (d) was an owner of a sole proprietorship or
14            partner in a partnership previously terminated,
15            suspended, or excluded from participation as a
16            vendor in the Illinois Medical Assistance Program,
17            or was previously revoked as an alternate payee in
18            the Illinois Medical Assistance Program, or was
19            terminated, suspended, or excluded from
20            participation as a vendor in a medical assistance
21            program in another state that is of the same kind
22            as the program of medical assistance provided
23            under Article V of this Code, during the time of
24            conduct which was the basis for that vendor's
25            termination, suspension, or exclusion or alternate
26            payee's revocation; or

 

 

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1            (6) the alternate payee, a person with management
2        responsibility for an alternate payee, an officer or
3        person owning, either directly or indirectly, 5% or
4        more of the shares of stock or other evidences of
5        ownership in a corporate alternate payee, or a partner
6        in a partnership which is an alternate payee:
7                (a) has engaged in conduct prohibited by
8            applicable federal or State law or regulation
9            relating to the Illinois Medical Assistance
10            Program; or
11                (b) was a person with management
12            responsibility for a vendor or alternate payee at
13            the time that the vendor or alternate payee engaged
14            in practices prohibited by applicable federal or
15            State law or regulation relating to the Illinois
16            Medical Assistance Program; or
17                (c) was an officer, or person owning, either
18            directly or indirectly, 5% or more of the shares of
19            stock or other evidences of ownership in a vendor
20            or alternate payee at the time such vendor or
21            alternate payee engaged in practices prohibited by
22            applicable federal or State law or regulation
23            relating to the Illinois Medical Assistance
24            Program; or
25                (d) was an owner of a sole proprietorship or
26            partner in a partnership which was a vendor or

 

 

HB5539 Enrolled- 43 -LRB099 19598 EGJ 43993 b

1            alternate payee at the time such vendor or
2            alternate payee engaged in practices prohibited by
3            applicable federal or State law or regulation
4            relating to the Illinois Medical Assistance
5            Program; or
6            (7) the direct or indirect ownership of the vendor
7        or alternate payee (including the ownership of a vendor
8        or alternate payee that is a partner's interest in a
9        vendor or alternate payee, or ownership of 5% or more
10        of the shares of stock or other evidences of ownership
11        in a corporate vendor or alternate payee) has been
12        transferred by an individual who is terminated,
13        suspended, or excluded or barred from participating as
14        a vendor or is prohibited or revoked as an alternate
15        payee to the individual's spouse, child, brother,
16        sister, parent, grandparent, grandchild, uncle, aunt,
17        niece, nephew, cousin, or relative by marriage.
18    (K) The Illinois Department of Healthcare and Family
19Services may withhold payments, in whole or in part, to a
20provider or alternate payee where there is credible evidence,
21received from State or federal law enforcement or federal
22oversight agencies or from the results of a preliminary
23Department audit, that the circumstances giving rise to the
24need for a withholding of payments may involve fraud or willful
25misrepresentation under the Illinois Medical Assistance
26program. The Department shall by rule define what constitutes

 

 

HB5539 Enrolled- 44 -LRB099 19598 EGJ 43993 b

1"credible" evidence for purposes of this subsection. The
2Department may withhold payments without first notifying the
3provider or alternate payee of its intention to withhold such
4payments. A provider or alternate payee may request a
5reconsideration of payment withholding, and the Department
6must grant such a request. The Department shall state by rule a
7process and criteria by which a provider or alternate payee may
8request full or partial release of payments withheld under this
9subsection. This request may be made at any time after the
10Department first withholds such payments.
11        (a) The Illinois Department must send notice of its
12    withholding of program payments within 5 days of taking
13    such action. The notice must set forth the general
14    allegations as to the nature of the withholding action, but
15    need not disclose any specific information concerning its
16    ongoing investigation. The notice must do all of the
17    following:
18            (1) State that payments are being withheld in
19        accordance with this subsection.
20            (2) State that the withholding is for a temporary
21        period, as stated in paragraph (b) of this subsection,
22        and cite the circumstances under which withholding
23        will be terminated.
24            (3) Specify, when appropriate, which type or types
25        of Medicaid claims withholding is effective.
26            (4) Inform the provider or alternate payee of the

 

 

HB5539 Enrolled- 45 -LRB099 19598 EGJ 43993 b

1        right to submit written evidence for reconsideration
2        of the withholding by the Illinois Department.
3            (5) Inform the provider or alternate payee that a
4        written request may be made to the Illinois Department
5        for full or partial release of withheld payments and
6        that such requests may be made at any time after the
7        Department first withholds such payments.
8        (b) All withholding-of-payment actions under this
9    subsection shall be temporary and shall not continue after
10    any of the following:
11            (1) The Illinois Department or the prosecuting
12        authorities determine that there is insufficient
13        evidence of fraud or willful misrepresentation by the
14        provider or alternate payee.
15            (2) Legal proceedings related to the provider's or
16        alternate payee's alleged fraud, willful
17        misrepresentation, violations of this Act, or
18        violations of the Illinois Department's administrative
19        rules are completed.
20            (3) The withholding of payments for a period of 3
21        years.
22        (c) The Illinois Department may adopt all rules
23    necessary to implement this subsection (K).
24    (K-5) The Illinois Department may withhold payments, in
25whole or in part, to a provider or alternate payee upon
26initiation of an audit, quality of care review, investigation

 

 

HB5539 Enrolled- 46 -LRB099 19598 EGJ 43993 b

1when there is a credible allegation of fraud, or the provider
2or alternate payee demonstrating a clear failure to cooperate
3with the Illinois Department such that the circumstances give
4rise to the need for a withholding of payments. As used in this
5subsection, "credible allegation" is defined to include an
6allegation from any source, including, but not limited to,
7fraud hotline complaints, claims data mining, patterns
8identified through provider audits, civil actions filed under
9the Illinois False Claims Act, and law enforcement
10investigations. An allegation is considered to be credible when
11it has indicia of reliability. The Illinois Department may
12withhold payments without first notifying the provider or
13alternate payee of its intention to withhold such payments. A
14provider or alternate payee may request a hearing or a
15reconsideration of payment withholding, and the Illinois
16Department must grant such a request. The Illinois Department
17shall state by rule a process and criteria by which a provider
18or alternate payee may request a hearing or a reconsideration
19for the full or partial release of payments withheld under this
20subsection. This request may be made at any time after the
21Illinois Department first withholds such payments.
22        (a) The Illinois Department must send notice of its
23    withholding of program payments within 5 days of taking
24    such action. The notice must set forth the general
25    allegations as to the nature of the withholding action but
26    need not disclose any specific information concerning its

 

 

HB5539 Enrolled- 47 -LRB099 19598 EGJ 43993 b

1    ongoing investigation. The notice must do all of the
2    following:
3            (1) State that payments are being withheld in
4        accordance with this subsection.
5            (2) State that the withholding is for a temporary
6        period, as stated in paragraph (b) of this subsection,
7        and cite the circumstances under which withholding
8        will be terminated.
9            (3) Specify, when appropriate, which type or types
10        of claims are withheld.
11            (4) Inform the provider or alternate payee of the
12        right to request a hearing or a reconsideration of the
13        withholding by the Illinois Department, including the
14        ability to submit written evidence.
15            (5) Inform the provider or alternate payee that a
16        written request may be made to the Illinois Department
17        for a hearing or a reconsideration for the full or
18        partial release of withheld payments and that such
19        requests may be made at any time after the Illinois
20        Department first withholds such payments.
21        (b) All withholding of payment actions under this
22    subsection shall be temporary and shall not continue after
23    any of the following:
24            (1) The Illinois Department determines that there
25        is insufficient evidence of fraud, or the provider or
26        alternate payee demonstrates clear cooperation with

 

 

HB5539 Enrolled- 48 -LRB099 19598 EGJ 43993 b

1        the Illinois Department, as determined by the Illinois
2        Department, such that the circumstances do not give
3        rise to the need for withholding of payments; or
4            (2) The withholding of payments has lasted for a
5        period in excess of 3 years.
6        (c) The Illinois Department may adopt all rules
7    necessary to implement this subsection (K-5).
8    (L) The Illinois Department shall establish a protocol to
9enable health care providers to disclose an actual or potential
10violation of this Section pursuant to a self-referral
11disclosure protocol, referred to in this subsection as "the
12protocol". The protocol shall include direction for health care
13providers on a specific person, official, or office to whom
14such disclosures shall be made. The Illinois Department shall
15post information on the protocol on the Illinois Department's
16public website. The Illinois Department may adopt rules
17necessary to implement this subsection (L). In addition to
18other factors that the Illinois Department finds appropriate,
19the Illinois Department may consider a health care provider's
20timely use or failure to use the protocol in considering the
21provider's failure to comply with this Code.
22    (M) Notwithstanding any other provision of this Code, the
23Illinois Department, at its discretion, may exempt an entity
24licensed under the Nursing Home Care Act, the ID/DD Community
25Care Act, or the MC/DD Act from the provisions of subsections
26(A-15), (B), and (C) of this Section if the licensed entity is

 

 

HB5539 Enrolled- 49 -LRB099 19598 EGJ 43993 b

1in receivership.
2(Source: P.A. 98-214, eff. 8-9-13; 98-550, eff. 8-27-13;
398-756, eff. 7-16-14; 99-180, eff. 7-29-15.)
 
4    Section 99. Effective date. This Act takes effect upon
5becoming law.