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90_HB0773
305 ILCS 5/12-13.1
Amends the "Administration" Article of the Public Aid
Code. Provides that the Inspector General within the
Department of Public Aid may establish a special
administrative subdivision to monitor managed health care
entities participating in the Medicaid integrated health care
program and to receive and investigate complaints concerning
that program. Effective immediately.
LRB9000970DJcd
LRB9000970DJcd
1 AN ACT to amend the Illinois Public Aid Code by changing
2 Section 12-13.1.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Public Aid Code is amended by
6 changing Section 12-13.1 as follows:
7 (305 ILCS 5/12-13.1)
8 (Text of Section before amendment by P.A. 89-507)
9 Sec. 12-13.1. Inspector General.
10 (a) The Governor shall appoint, and the Senate shall
11 confirm, an Inspector General who shall function within the
12 Illinois Department and report to the Governor. The term of
13 the Inspector General shall expire on the third Monday of
14 January, 1997 and every 4 years thereafter.
15 (b) In order to prevent, detect, and eliminate fraud,
16 waste, abuse, mismanagement, and misconduct, the Inspector
17 General shall oversee the Illinois Department's integrity
18 functions, which include, but are not limited to, the
19 following:
20 (1) Investigation of misconduct by employees,
21 vendors, contractors and medical providers.
22 (2) Audits of medical providers related to ensuring
23 that appropriate payments are made for services rendered
24 and to the recovery of overpayments.
25 (3) Monitoring of quality assurance programs
26 generally related to the medical assistance program and
27 specifically related to any managed care program.
28 (4) Quality control measurements of the programs
29 administered by the Illinois Department.
30 (5) Investigations of fraud or intentional program
31 violations committed by clients of the Illinois
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1 Department.
2 (6) Actions initiated against contractors or
3 medical providers for any of the following reasons:
4 (A) Violations of the medical assistance
5 program.
6 (B) Sanctions against providers brought in
7 conjunction with the Department of Public Health or
8 the Department of Mental Health and Developmental
9 Disabilities.
10 (C) Recoveries of assessments against
11 hospitals and long-term care facilities.
12 (D) Sanctions mandated by the United States
13 Department of Health and Human Services against
14 medical providers.
15 (E) Violations of contracts related to any
16 managed care programs.
17 (7) Representation of the Illinois Department at
18 hearings with the Illinois Department of Professional
19 Regulation in actions taken against professional licenses
20 held by persons who are in violation of orders for child
21 support payments.
22 (b-7) The Inspector General may establish within that
23 Office a special administrative subdivision to monitor
24 managed health care entities participating in the integrated
25 health care program established under Section 5-16.3 of this
26 Code to ensure that the entities comply with the requirements
27 of that Section. This special administrative subdivision may
28 receive and investigate complaints made by persons enrolled
29 in a managed health care entity's health care delivery
30 system. If the Inspector General investigates a complaint,
31 the Inspector General shall determine whether a managed
32 health care entity has complied with the requirements of
33 Section 5-16.3 and the rules implementing that Section to the
34 extent that those issues are raised by the complaint.
-3- LRB9000970DJcd
1 (c) The Inspector General shall have access to all
2 information, personnel and facilities of the Illinois
3 Department, its employees, vendors, contractors and medical
4 providers and any federal, State or local governmental agency
5 that are necessary to perform the duties of the Office as
6 directly related to public assistance programs administered
7 by the Illinois Department. No medical provider shall be
8 compelled, however, to provide individual medical records of
9 patients who are not clients of the Medical Assistance
10 Program. State and local governmental agencies are
11 authorized and directed to provide the requested information,
12 assistance or cooperation.
13 (d) The Inspector General shall serve as the Illinois
14 Department's primary liaison with law enforcement,
15 investigatory and prosecutorial agencies, including but not
16 limited to the following:
17 (1) The Department of State Police.
18 (2) The Federal Bureau of Investigation and other
19 federal law enforcement agencies.
20 (3) The various Inspectors General of federal
21 agencies overseeing the programs administered by the
22 Illinois Department.
23 (4) The various Inspectors General of any other
24 State agencies with responsibilities for portions of
25 programs primarily administered by the Illinois
26 Department.
27 (5) The Offices of the several United States
28 Attorneys in Illinois.
29 (6) The several State's Attorneys.
30 The Inspector General shall meet on a regular basis with
31 these entities to share information regarding possible
32 misconduct by any persons or entities involved with the
33 public aid programs administered by the Illinois Department.
34 (e) All investigations conducted by the Inspector
-4- LRB9000970DJcd
1 General shall be conducted in a manner that ensures the
2 preservation of evidence for use in criminal prosecutions.
3 If the Inspector General determines that a possible criminal
4 act relating to fraud in the provision or administration of
5 the medical assistance program has been committed, the
6 Inspector General shall immediately notify the Medicaid Fraud
7 Control Unit. If the Inspector General determines that a
8 possible criminal act has been committed within the
9 jurisdiction of the Office, the Inspector General may request
10 the special expertise of the Department of State Police. The
11 Inspector General may present for prosecution the findings of
12 any criminal investigation to the Office of the Attorney
13 General, the Offices of the several United State Attorneys in
14 Illinois or the several State's Attorneys.
15 (f) To carry out his or her duties as described in this
16 Section, the Inspector General and his or her designees shall
17 have the power to compel by subpoena the attendance and
18 testimony of witnesses and the production of books,
19 electronic records and papers as directly related to public
20 assistance programs administered by the Illinois Department.
21 No medical provider shall be compelled, however, to provide
22 individual medical records of patients who are not clients of
23 the Medical Assistance Program.
24 (g) The Inspector General shall report all convictions,
25 terminations, and suspensions taken against vendors,
26 contractors and medical providers to the Illinois Department
27 and to any agency responsible for licensing or regulating
28 those persons or entities.
29 (h) The Inspector General shall make quarterly reports,
30 findings, and recommendations regarding the Office's
31 investigations into reports of fraud, waste, abuse,
32 mismanagement, or misconduct relating to any public aid
33 programs administered by the Illinois Department to the
34 General Assembly and the Governor. These reports shall
-5- LRB9000970DJcd
1 include, but not be limited to, the following information:
2 (1) Aggregate provider billing and payment
3 information, including the number of providers at various
4 Medicaid earning levels.
5 (2) The number of audits of the medical assistance
6 program and the dollar savings resulting from those
7 audits.
8 (3) The number of prescriptions rejected annually
9 under the Illinois Department's Refill Too Soon program
10 and the dollar savings resulting from that program.
11 (4) Provider sanctions, in the aggregate, including
12 terminations and suspensions.
13 (5) A detailed summary of the investigations
14 undertaken in the previous fiscal year. These summaries
15 shall comply with all laws and rules regarding
16 maintaining confidentiality in the public aid programs.
17 (i) Nothing in this Section shall limit investigations
18 by the Illinois Department that may otherwise be required by
19 law or that may be necessary in the Illinois Department's
20 capacity as the central administrative authority responsible
21 for administration of public aid programs in this State.
22 (Source: P.A. 88-554, eff. 7-26-94.)
23 (Text of Section after amendment by P.A. 89-507)
24 Sec. 12-13.1. Inspector General.
25 (a) The Governor shall appoint, and the Senate shall
26 confirm, an Inspector General who shall function within the
27 Illinois Department of Public Aid and report to the Governor.
28 The term of the Inspector General shall expire on the third
29 Monday of January, 1997 and every 4 years thereafter.
30 (b) In order to prevent, detect, and eliminate fraud,
31 waste, abuse, mismanagement, and misconduct, the Inspector
32 General shall oversee the Illinois Department of Public Aid's
33 integrity functions, which include, but are not limited to,
34 the following:
-6- LRB9000970DJcd
1 (1) Investigation of misconduct by employees,
2 vendors, contractors and medical providers.
3 (2) Audits of medical providers related to ensuring
4 that appropriate payments are made for services rendered
5 and to the recovery of overpayments.
6 (3) Monitoring of quality assurance programs
7 generally related to the medical assistance program and
8 specifically related to any managed care program.
9 (4) Quality control measurements of the programs
10 administered by the Illinois Department of Public Aid.
11 (5) Investigations of fraud or intentional program
12 violations committed by clients of the Illinois
13 Department of Public Aid.
14 (6) Actions initiated against contractors or
15 medical providers for any of the following reasons:
16 (A) Violations of the medical assistance
17 program.
18 (B) Sanctions against providers brought in
19 conjunction with the Department of Public Health or
20 the Department of Human Services (as successor to
21 the Department of Mental Health and Developmental
22 Disabilities).
23 (C) Recoveries of assessments against
24 hospitals and long-term care facilities.
25 (D) Sanctions mandated by the United States
26 Department of Health and Human Services against
27 medical providers.
28 (E) Violations of contracts related to any
29 managed care programs.
30 (7) Representation of the Illinois Department of
31 Public Aid at hearings with the Illinois Department of
32 Professional Regulation in actions taken against
33 professional licenses held by persons who are in
34 violation of orders for child support payments.
-7- LRB9000970DJcd
1 (b-5) At the request of the Secretary of Human Services,
2 the Inspector General shall, in relation to any function
3 performed by the Department of Human Services as successor to
4 the Department of Public Aid, exercise one or more of the
5 powers provided under this Section as if those powers related
6 to the Department of Human Services; in such matters, the
7 Inspector General shall report his or her findings to the
8 Secretary of Human Services.
9 (b-7) The Inspector General may establish within that
10 Office a special administrative subdivision to monitor
11 managed health care entities participating in the integrated
12 health care program established under Section 5-16.3 of this
13 Code to ensure that the entities comply with the requirements
14 of that Section. This special administrative subdivision may
15 receive and investigate complaints made by persons enrolled
16 in a managed health care entity's health care delivery
17 system. If the Inspector General investigates a complaint,
18 the Inspector General shall determine whether a managed
19 health care entity has complied with the requirements of
20 Section 5-16.3 and the rules implementing that Section to the
21 extent that those issues are raised by the complaint.
22 (c) The Inspector General shall have access to all
23 information, personnel and facilities of the Illinois
24 Department of Public Aid and the Department of Human Services
25 (as successor to the Department of Public Aid), their
26 employees, vendors, contractors and medical providers and any
27 federal, State or local governmental agency that are
28 necessary to perform the duties of the Office as directly
29 related to public assistance programs administered by those
30 departments. No medical provider shall be compelled,
31 however, to provide individual medical records of patients
32 who are not clients of the Medical Assistance Program. State
33 and local governmental agencies are authorized and directed
34 to provide the requested information, assistance or
-8- LRB9000970DJcd
1 cooperation.
2 (d) The Inspector General shall serve as the Illinois
3 Department of Public Aid's primary liaison with law
4 enforcement, investigatory and prosecutorial agencies,
5 including but not limited to the following:
6 (1) The Department of State Police.
7 (2) The Federal Bureau of Investigation and other
8 federal law enforcement agencies.
9 (3) The various Inspectors General of federal
10 agencies overseeing the programs administered by the
11 Illinois Department of Public Aid.
12 (4) The various Inspectors General of any other
13 State agencies with responsibilities for portions of
14 programs primarily administered by the Illinois
15 Department of Public Aid.
16 (5) The Offices of the several United States
17 Attorneys in Illinois.
18 (6) The several State's Attorneys.
19 The Inspector General shall meet on a regular basis with
20 these entities to share information regarding possible
21 misconduct by any persons or entities involved with the
22 public aid programs administered by the Illinois Department
23 of Public Aid.
24 (e) All investigations conducted by the Inspector
25 General shall be conducted in a manner that ensures the
26 preservation of evidence for use in criminal prosecutions.
27 If the Inspector General determines that a possible criminal
28 act relating to fraud in the provision or administration of
29 the medical assistance program has been committed, the
30 Inspector General shall immediately notify the Medicaid Fraud
31 Control Unit. If the Inspector General determines that a
32 possible criminal act has been committed within the
33 jurisdiction of the Office, the Inspector General may request
34 the special expertise of the Department of State Police. The
-9- LRB9000970DJcd
1 Inspector General may present for prosecution the findings of
2 any criminal investigation to the Office of the Attorney
3 General, the Offices of the several United State Attorneys in
4 Illinois or the several State's Attorneys.
5 (f) To carry out his or her duties as described in this
6 Section, the Inspector General and his or her designees shall
7 have the power to compel by subpoena the attendance and
8 testimony of witnesses and the production of books,
9 electronic records and papers as directly related to public
10 assistance programs administered by the Illinois Department
11 of Public Aid or the Department of Human Services (as
12 successor to the Department of Public Aid). No medical
13 provider shall be compelled, however, to provide individual
14 medical records of patients who are not clients of the
15 Medical Assistance Program.
16 (g) The Inspector General shall report all convictions,
17 terminations, and suspensions taken against vendors,
18 contractors and medical providers to the Illinois Department
19 of Public Aid and to any agency responsible for licensing or
20 regulating those persons or entities.
21 (h) The Inspector General shall make quarterly reports,
22 findings, and recommendations regarding the Office's
23 investigations into reports of fraud, waste, abuse,
24 mismanagement, or misconduct relating to any public aid
25 programs administered by the Illinois Department of Public
26 Aid or the Department of Human Services (as successor to the
27 Department of Public Aid) to the General Assembly and the
28 Governor. These reports shall include, but not be limited
29 to, the following information:
30 (1) Aggregate provider billing and payment
31 information, including the number of providers at various
32 Medicaid earning levels.
33 (2) The number of audits of the medical assistance
34 program and the dollar savings resulting from those
-10- LRB9000970DJcd
1 audits.
2 (3) The number of prescriptions rejected annually
3 under the Illinois Department of Public Aid's Refill Too
4 Soon program and the dollar savings resulting from that
5 program.
6 (4) Provider sanctions, in the aggregate, including
7 terminations and suspensions.
8 (5) A detailed summary of the investigations
9 undertaken in the previous fiscal year. These summaries
10 shall comply with all laws and rules regarding
11 maintaining confidentiality in the public aid programs.
12 (i) Nothing in this Section shall limit investigations
13 by the Illinois Department of Public Aid or the Department of
14 Human Services that may otherwise be required by law or that
15 may be necessary in their capacity as the central
16 administrative authorities responsible for administration of
17 public aid programs in this State.
18 (Source: P.A. 88-554, eff. 7-26-94; 89-507, eff. 7-1-97.)
19 Section 95. No acceleration or delay. Where this Act
20 makes changes in a statute that is represented in this Act by
21 text that is not yet or no longer in effect (for example, a
22 Section represented by multiple versions), the use of that
23 text does not accelerate or delay the taking effect of (i)
24 the changes made by this Act or (ii) provisions derived from
25 any other Public Act.
26 Section 99. Effective date. This Act takes effect upon
27 becoming law.