HB 1521

1	A bill to be entitled
2	An act relating to health care fraud; amending s. 400.471,
3	F.S.; prohibiting the Agency for Health Care
4	Administration from issuing an initial license to a home
5	health agency for the purpose of opening a new home health
6	agency under certain conditions until a specified date;
7	prohibiting the agency from issuing a change-of-ownership
8	license to a home health agency under certain conditions
9	until a specified date; providing an exception; amending
10	s. 400.474, F.S.; authorizing the agency to revoke a home
11	health agency license if the applicant or any controlling
12	interest has been sanctioned for acts specified under s.
13	400.471(10), F.S.; amending s. 408.815, F.S.; revising the
14	grounds upon which the agency may deny or revoke an
15	application for an initial license, a change-of-ownership
16	license, or a licensure renewal for certain health care
17	entities listed in s. 408.802, F.S.; amending s. 409.907,
18	F.S.; extending the number of years that Medicaid
19	providers must retain Medicaid recipient records; adding
20	additional requirements to the Medicaid provider
21	agreement; revising applicability of screening
22	requirements; revising conditions under which the agency
23	is authorized to deny a Medicaid provider application;
24	amending s. 409.912, F.S.; revising requirements for
25	Medicaid prepaid, fixed-sum, and managed care contracts;
26	amending s. 409.913, F.S.; removing a required element
27	from the joint Medicaid fraud and abuse report submitted
28	by the agency and the Medicaid Fraud Control Unit of the
29	Department of Legal Affairs; extending the number of years
30	that Medicaid providers must retain Medicaid recipient
31	records; authorizing the Medicaid program integrity staff
32	to immediately suspend or terminate a Medicaid provider
33	for engaging in specified conduct; removing a requirement
34	for the agency to hold suspended Medicaid payments in a
35	separate account; authorizing the agency to deny payment
36	or require repayment to Medicaid providers convicted of
37	certain crimes; authorizing the agency to terminate a
38	Medicaid provider if the provider fails to reimburse a
39	fine determined by a final order; authorizing the agency
40	to withhold Medicaid reimbursement to a Medicaid provider
41	that fails to pay a fine determined by a final order,
42	fails to enter into a repayment plan, or fails to comply
43	with a repayment plan or settlement agreement; amending s.
44	409.9203, F.S.; providing that certain state employees are
45	ineligible from receiving a reward for reporting Medicaid
46	fraud; amending s. 456.001, F.S.; defining the term
47	"affiliate" or "affiliated person" as it relates to health
48	professions and occupations; amending s. 456.041, F.S.;
49	requiring the Department of Health to include
50	administrative complaint, arrest, and any conviction
51	information relating to the practitioner's profile;
52	providing a disclaimer; amending s. 456.072, F.S.;
53	clarifying a ground under which disciplinary actions may
54	be taken; amending s. 456.073, F.S.; revising
55	applicability of investigations and administrative
56	complaints to include Medicaid fraud; amending s. 456.074,
57	F.S.; authorizing the Department of Health to issue an
58	emergency order suspending the license of any person
59	licensed under ch. 456, F.S., who engages in specified
60	criminal conduct; providing an effective date.
61
62	Be It Enacted by the Legislature of the State of Florida:
63
64	Section 1. Subsection (11) of section 400.471, Florida
65	Statutes, is amended to read:
66	400.471 Application for license; fee.-
67	(11)(a) The agency may not issue an initial license to a
68	home health agency under part II of chapter 408 or this part for
69	the purpose of opening a new home health agency until July 1,
70	2012 2010, in any county that has at least one actively licensed
71	home health agency and a population of persons 65 years of age
72	or older, as indicated in the most recent population estimates
73	published by the Executive Office of the Governor, of fewer than
74	1,200 per home health agency. In such counties, for any
75	application received by the agency prior to July 1, 2009, which
76	has been deemed by the agency to be complete except for proof of
77	accreditation, the agency may issue an initial ownership license
78	only if the applicant has applied for accreditation before May
79	1, 2009, from an accrediting organization that is recognized by
80	the agency.
81	(b) Effective October 1, 2009, the agency may not issue a
82	change of ownership license to a home health agency under part
83	II of chapter 408 or this part until July 1, 2012 2010, in any
84	county that has at least one actively licensed home health
85	agency and a population of persons 65 years of age or older, as
86	indicated in the most recent population estimates published by
87	the Executive Office of the Governor, of fewer than 1,200 per
88	home health agency. In such counties, for any application
89	received by the agency before prior to October 1, 2009, which
90	has been deemed by the agency to be complete except for proof of
91	accreditation, the agency may issue a change of ownership
92	license only if the applicant has applied for accreditation
93	before August 1, 2009, from an accrediting organization that is
94	recognized by the agency. This paragraph does not apply to an
95	application for a change of ownership submitted by a home health
96	agency that is accredited, has been licensed by the state for at
97	least 5 years, and is in good standing with the agency.
98	Section 2. Subsection (8) is added to section 400.474,
99	Florida Statutes, to read:
100	400.474 Administrative penalties.-
101	(8) The agency may revoke the license of a home health
102	agency that is not be eligible for licensure renewal under s.
103	400.471(10).
104	Section 3. Subsection (4) of section 408.815, Florida
105	Statutes, is amended, and subsection (5) is added to that
106	section, to read:
107	408.815 License or application denial; revocation.-
108	(4) In addition to the grounds provided in authorizing
109	statutes, the agency shall deny an application for an initial a
110	license or a change-of-ownership license renewal if the
111	applicant or a person having a controlling interest in an
112	applicant has been:
113	(a) Has been convicted of, or enters a plea of guilty or
114	nolo contendere to, regardless of adjudication, a felony under
115	chapter 409, chapter 817, chapter 893, or a similar felony
116	offense committed in another state or jurisdiction 21 U.S.C. ss.
117	801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and any
118	subsequent period of probation for such convictions or plea
119	ended more than 15 years before prior to the date of the
120	application;
121	(b) Has been convicted of, or enters a plea of guilty or
122	nolo contendere to, regardless of adjudication, a felony under
123	21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396, unless the
124	sentence and any subsequent period of probation for such
125	conviction or plea ended more than 15 years before the date of
126	the application;
127	(c)(b) Has been terminated for cause from the Florida
128	Medicaid program pursuant to s. 409.913, unless the applicant
129	has been in good standing with the Florida Medicaid program for
130	the most recent 5 years; or
131	(d)(c) Has been terminated for cause, pursuant to the
132	appeals procedures established by the state or Federal
133	Government, from the federal Medicare program or from any other
134	state Medicaid program, unless the applicant has been in good
135	standing with a state Medicaid program or the federal Medicare
136	program for the most recent 5 years and the termination occurred
137	at least 20 years before prior to the date of the application;
138	or
139	(e) Is listed on the United States Department of Health
140	and Human Services Office of Inspector General's List of
141	Excluded Individuals and Entities.
142	(5) In addition to the grounds provided in authorizing
143	statutes, the agency shall deny an application for licensure
144	renewal if the applicant or a person having a controlling
145	interest in an applicant:
146	(a) Has been convicted of, or enters a plea of guilty or
147	nolo contendere to, regardless of adjudication, a felony under
148	chapter 409, chapter 817, chapter 893, or a similar felony
149	offense committed in another state or jurisdiction since July 1,
150	2009;
151	(b) Has been convicted of, or enters a plea of guilty or
152	nolo contendere to, regardless of adjudication, a felony under
153	21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396 since July 1,
154	2009;
155	(c) Has been terminated for cause from the Florida
156	Medicaid program pursuant to s. 409.913, unless the applicant
157	has been in good standing with the Florida Medicaid program for
158	the most recent 5 years;
159	(d) Has been terminated for cause, pursuant to the appeals
160	procedures established by the state, from any other state
161	Medicaid program, unless the applicant has been in good standing
162	with a state Medicaid program for the most recent 5 years and
163	the termination occurred at least 20 years before the date of
164	the application; or
165	(e) Is listed on the United States Department of Health
166	and Human Services Office of Inspector General's List of
167	Excluded Individuals and Entities.
168	Section 4. Paragraph (c) of subsection (3) of section
169	409.907, Florida Statutes, is amended, paragraph (k) is added to
170	that subsection, and subsection (8), paragraph (b) of subsection
171	(9), and subsection (10) of that section are amended, to read:
172	409.907 Medicaid provider agreements.-The agency may make
173	payments for medical assistance and related services rendered to
174	Medicaid recipients only to an individual or entity who has a
175	provider agreement in effect with the agency, who is performing
176	services or supplying goods in accordance with federal, state,
177	and local law, and who agrees that no person shall, on the
178	grounds of handicap, race, color, or national origin, or for any
179	other reason, be subjected to discrimination under any program
180	or activity for which the provider receives payment from the
181	agency.
182	(3) The provider agreement developed by the agency, in
183	addition to the requirements specified in subsections (1) and
184	(2), shall require the provider to:
185	(c) Retain all medical and Medicaid-related records for a
186	period of 6 5 years to satisfy all necessary inquiries by the
187	agency.
188	(k) Report any change of any principal of the provider,
189	including any officer, director, billing agent, managing
190	employee, or affiliated person, or any partner or shareholder
191	who has an ownership interest equal to 5 percent or more in the
192	provider. The provider must report changes to the agency no
193	later than 30 days after the change occurs.
194	(8)(a) Each provider, or each principal of the provider if
195	the provider is a corporation, partnership, association, or
196	other entity, seeking to participate in the Medicaid program
197	must submit a complete set of his or her fingerprints to the
198	agency for the purpose of conducting a criminal history record
199	check. Principals of the provider include any officer, director,
200	billing agent, managing employee, or affiliated person, or any
201	partner or shareholder who has an ownership interest equal to 5
202	percent or more in the provider. However, a director of a not-
203	for-profit corporation or organization is not a principal for
204	purposes of a background investigation as required by this
205	section if the director: serves solely in a voluntary capacity
206	for the corporation or organization, does not regularly take
207	part in the day-to-day operational decisions of the corporation
208	or organization, receives no remuneration from the not-for-
209	profit corporation or organization for his or her service on the
210	board of directors, has no financial interest in the not-for-
211	profit corporation or organization, and has no family members
212	with a financial interest in the not-for-profit corporation or
213	organization; and if the director submits an affidavit, under
214	penalty of perjury, to this effect to the agency and the not-
215	for-profit corporation or organization submits an affidavit,
216	under penalty of perjury, to this effect to the agency as part
217	of the corporation's or organization's Medicaid provider
218	agreement application. Notwithstanding the above, the agency may
219	require a background check for any person reasonably suspected
220	by the agency to have been convicted of a crime. This subsection
221	shall not apply to:
222	1. A hospital licensed under chapter 395;
223	2. A nursing home licensed under chapter 400;
224	3. A hospice licensed under chapter 400;
225	4. An assisted living facility licensed under chapter 429;
226	1.5. A unit of local government, except that requirements
227	of this subsection apply to nongovernmental providers and
228	entities when contracting with the local government to provide
229	Medicaid services. The actual cost of the state and national
230	criminal history record checks must be borne by the
231	nongovernmental provider or entity; or
232	2.6. Any business that derives more than 50 percent of its
233	revenue from the sale of goods to the final consumer, and the
234	business or its controlling parent either is required to file a
235	form 10-K or other similar statement with the Securities and
236	Exchange Commission or has a net worth of $50 million or more.
237	(b) Background screening shall be conducted in accordance
238	with chapter 435 and s. 408.809. The agency shall submit the
239	fingerprints to the Department of Law Enforcement. The
240	department shall conduct a state criminal-background
241	investigation and forward the fingerprints to the Federal Bureau
242	of Investigation for a national criminal-history record check.
243	The cost of the state and national criminal record check shall
244	be borne by the provider.
245	(c) The agency may permit a provider to participate in the
246	Medicaid program pending the results of the criminal record
247	check. However, such permission is fully revocable if the record
248	check reveals any crime-related history as provided in
249	subsection (10).
250	(c)(d) Proof of compliance with the requirements of level
251	2 screening under s. 435.04 conducted within 12 months prior to
252	the date that the Medicaid provider application is submitted to
253	the agency shall fulfill the requirements of this subsection.
254	Proof of compliance with the requirements of level 1 screening
255	under s. 435.03 conducted within 12 months prior to the date
256	that the Medicaid provider application is submitted to the
257	agency shall meet the requirement that the Department of Law
258	Enforcement conduct a state criminal history record check.
259	(9) Upon receipt of a completed, signed, and dated
260	application, and completion of any necessary background
261	investigation and criminal history record check, the agency must
262	either:
263	(b) Deny the application if the agency finds that it is in
264	the best interest of the Medicaid program to do so. The agency
265	may consider any the factors listed in subsection (10), as well
266	as any other factor that could affect the effective and
267	efficient administration of the program, including, but not
268	limited to, the applicant's demonstrated ability to provide
269	services, conduct business, and operate a financially viable
270	concern; the current availability of medical care, services, or
271	supplies to recipients, taking into account geographic location
272	and reasonable travel time; the number of providers of the same
273	type already enrolled in the same geographic area; and the
274	credentials, experience, success, and patient outcomes of the
275	provider for the services that it is making application to
276	provide in the Medicaid program. The agency shall deny the
277	application if the agency finds that a provider; any officer,
278	director, agent, managing employee, or affiliated person; or any
279	principal, partner, or shareholder having an ownership interest
280	equal to 5 percent or greater in the provider if the provider is
281	a corporation, partnership, or other business entity, has failed
282	to pay all outstanding fines or overpayments assessed by final
283	order of the agency or final order of the Centers for Medicare
284	and Medicaid Services, not subject to further appeal, unless the
285	provider agrees to a repayment plan that includes withholding
286	Medicaid reimbursement until the amount due is paid in full.
287	(10) The agency shall deny the application if may consider
288	whether the provider, or any principal, officer, director,
289	agent, managing employee, or affiliated person, or any partner
290	or shareholder having an ownership interest equal to 5 percent
291	or greater in the provider if the provider is a corporation,
292	partnership, or other business entity, has committed an offense
293	listed in s. 409.913(13), and may deny the application if one of
294	these persons has:
295	(a) Made a false representation or omission of any
296	material fact in making the application, including the
297	submission of an application that conceals the controlling or
298	ownership interest of any principal, officer, director, agent,
299	managing employee, affiliated person, or partner or shareholder
300	who may not be eligible to participate;
301	(b) Been or is currently excluded, suspended, terminated
302	from, or has involuntarily withdrawn from participation in,
303	Florida's Medicaid program or any other state's Medicaid
304	program, or from participation in any other governmental or
305	private health care or health insurance program;
306	(c) Been convicted of a criminal offense relating to the
307	delivery of any goods or services under Medicaid or Medicare or
308	any other public or private health care or health insurance
309	program including the performance of management or
310	administrative services relating to the delivery of goods or
311	services under any such program;
312	(d) Been convicted under federal or state law of a
313	criminal offense related to the neglect or abuse of a patient in
314	connection with the delivery of any health care goods or
315	services;
316	(c)(e) Been convicted under federal or state law of a
317	criminal offense relating to the unlawful manufacture,
318	distribution, prescription, or dispensing of a controlled
319	substance;
320	(d)(f) Been convicted of any criminal offense relating to
321	fraud, theft, embezzlement, breach of fiduciary responsibility,
322	or other financial misconduct;
323	(e)(g) Been convicted under federal or state law of a
324	crime punishable by imprisonment of a year or more which
325	involves moral turpitude;
326	(f)(h) Been convicted in connection with the interference
327	or obstruction of any investigation into any criminal offense
328	listed in this subsection;
329	(g)(i) Been found to have violated federal or state laws,
330	rules, or regulations governing Florida's Medicaid program or
331	any other state's Medicaid program, the Medicare program, or any
332	other publicly funded federal or state health care or health
333	insurance program, and been sanctioned accordingly;
334	(h)(j) Been previously found by a licensing, certifying,
335	or professional standards board or agency to have violated the
336	standards or conditions relating to licensure or certification
337	or the quality of services provided; or
338	(i)(k) Failed to pay any fine or overpayment properly
339	assessed under the Medicaid program in which no appeal is
340	pending or after resolution of the proceeding by stipulation or
341	agreement, unless the agency has issued a specific letter of
342	forgiveness or has approved a repayment schedule to which the
343	provider agrees to adhere.
344	Section 5. Subsections (10) and (32) of section 409.912,
345	Florida Statutes, are amended to read:
346	409.912 Cost-effective purchasing of health care.-The
347	agency shall purchase goods and services for Medicaid recipients
348	in the most cost-effective manner consistent with the delivery
349	of quality medical care. To ensure that medical services are
350	effectively utilized, the agency may, in any case, require a
351	confirmation or second physician's opinion of the correct
352	diagnosis for purposes of authorizing future services under the
353	Medicaid program. This section does not restrict access to
354	emergency services or poststabilization care services as defined
355	in 42 C.F.R. part 438.114. Such confirmation or second opinion
356	shall be rendered in a manner approved by the agency. The agency
357	shall maximize the use of prepaid per capita and prepaid
358	aggregate fixed-sum basis services when appropriate and other
359	alternative service delivery and reimbursement methodologies,
360	including competitive bidding pursuant to s. 287.057, designed
361	to facilitate the cost-effective purchase of a case-managed
362	continuum of care. The agency shall also require providers to
363	minimize the exposure of recipients to the need for acute
364	inpatient, custodial, and other institutional care and the
365	inappropriate or unnecessary use of high-cost services. The
366	agency shall contract with a vendor to monitor and evaluate the
367	clinical practice patterns of providers in order to identify
368	trends that are outside the normal practice patterns of a
369	provider's professional peers or the national guidelines of a
370	provider's professional association. The vendor must be able to
371	provide information and counseling to a provider whose practice
372	patterns are outside the norms, in consultation with the agency,
373	to improve patient care and reduce inappropriate utilization.
374	The agency may mandate prior authorization, drug therapy
375	management, or disease management participation for certain
376	populations of Medicaid beneficiaries, certain drug classes, or
377	particular drugs to prevent fraud, abuse, overuse, and possible
378	dangerous drug interactions. The Pharmaceutical and Therapeutics
379	Committee shall make recommendations to the agency on drugs for
380	which prior authorization is required. The agency shall inform
381	the Pharmaceutical and Therapeutics Committee of its decisions
382	regarding drugs subject to prior authorization. The agency is
383	authorized to limit the entities it contracts with or enrolls as
384	Medicaid providers by developing a provider network through
385	provider credentialing. The agency may competitively bid single-
386	source-provider contracts if procurement of goods or services
387	results in demonstrated cost savings to the state without
388	limiting access to care. The agency may limit its network based
389	on the assessment of beneficiary access to care, provider
390	availability, provider quality standards, time and distance
391	standards for access to care, the cultural competence of the
392	provider network, demographic characteristics of Medicaid
393	beneficiaries, practice and provider-to-beneficiary standards,
394	appointment wait times, beneficiary use of services, provider
395	turnover, provider profiling, provider licensure history,
396	previous program integrity investigations and findings, peer
397	review, provider Medicaid policy and billing compliance records,
398	clinical and medical record audits, and other factors. Providers
399	shall not be entitled to enrollment in the Medicaid provider
400	network. The agency shall determine instances in which allowing
401	Medicaid beneficiaries to purchase durable medical equipment and
402	other goods is less expensive to the Medicaid program than long-
403	term rental of the equipment or goods. The agency may establish
404	rules to facilitate purchases in lieu of long-term rentals in
405	order to protect against fraud and abuse in the Medicaid program
406	as defined in s. 409.913. The agency may seek federal waivers
407	necessary to administer these policies.
408	(10) The agency shall not contract on a prepaid or fixed-
409	sum basis for Medicaid services with an entity which knows or
410	reasonably should know that any principal, officer, director,
411	agent, managing employee, or owner of stock or beneficial
412	interest in excess of 5 percent common or preferred stock, or
413	the entity itself, has been found guilty of, regardless of
414	adjudication, or entered a plea of nolo contendere, or guilty,
415	to:
416	(a) An offense listed in s. 408.809, s. 409.913(13), or s.
417	435.04 Fraud;
418	(b) Violation of federal or state antitrust statutes,
419	including those proscribing price fixing between competitors and
420	the allocation of customers among competitors;
421	(c) Commission of a felony involving embezzlement, theft,
422	forgery, income tax evasion, bribery, falsification or
423	destruction of records, making false statements, receiving
424	stolen property, making false claims, or obstruction of justice;
425	or
426	(d) Any crime in any jurisdiction which directly relates
427	to the provision of health services on a prepaid or fixed-sum
428	basis.
429	(32) Each managed care plan that is under contract with
430	the agency to provide health care services to Medicaid
431	recipients shall annually conduct a background check with the
432	Florida Department of Law Enforcement of all persons with
433	ownership interest of 5 percent or more or executive management
434	responsibility for the managed care plan and shall submit to the
435	agency information concerning any such person who has been found
436	guilty of, regardless of adjudication, or has entered a plea of
437	nolo contendere or guilty to, any of the offenses listed in s.
438	408.809, s. 409.913(13), or s. 435.04 s. 435.03.
439	Section 6. Section 409.913, Florida Statutes, is amended
440	to read:
441	409.913 Oversight of the integrity of the Medicaid
442	program.-The agency shall operate a program to oversee the
443	activities of Florida Medicaid recipients, and providers and
444	their representatives, to ensure that fraudulent and abusive
445	behavior and neglect of recipients occur to the minimum extent
446	possible, and to recover overpayments and impose sanctions as
447	appropriate. Beginning January 1, 2003, and each year
448	thereafter, the agency and the Medicaid Fraud Control Unit of
449	the Department of Legal Affairs shall submit a joint report to
450	the Legislature documenting the effectiveness of the state's
451	efforts to control Medicaid fraud and abuse and to recover
452	Medicaid overpayments during the previous fiscal year. The
453	report must describe the number of cases opened and investigated
454	each year; the sources of the cases opened; the disposition of
455	the cases closed each year; the amount of overpayments alleged
456	in preliminary and final audit letters; the number and amount of
457	fines or penalties imposed; any reductions in overpayment
458	amounts negotiated in settlement agreements or by other means;
459	the amount of final agency determinations of overpayments; the
460	amount deducted from federal claiming as a result of
461	overpayments; the amount of overpayments recovered each year;
462	the amount of cost of investigation recovered each year; the
463	average length of time to collect from the time the case was
464	opened until the overpayment is paid in full; the amount
465	determined as uncollectible and the portion of the uncollectible
466	amount subsequently reclaimed from the Federal Government; the
467	number of providers, by type, that are terminated from
468	participation in the Medicaid program as a result of fraud and
469	abuse; and all costs associated with discovering and prosecuting
470	cases of Medicaid overpayments and making recoveries in such
471	cases. The report must also document actions taken to prevent
472	overpayments and the number of providers prevented from
473	enrolling in or reenrolling in the Medicaid program as a result
474	of documented Medicaid fraud and abuse and must include policy
475	recommendations necessary to prevent or recover overpayments and
476	changes necessary to prevent and detect Medicaid fraud. All
477	policy recommendations in the report must include a detailed
478	fiscal analysis, including, but not limited to, implementation
479	costs, estimated savings to the Medicaid program, and the return
480	on investment. The agency must submit the policy recommendations
481	and fiscal analyses in the report to the appropriate estimating
482	conference, pursuant to s. 216.137, by February 15 of each year.
483	The agency and the Medicaid Fraud Control Unit of the Department
484	of Legal Affairs each must include detailed unit-specific
485	performance standards, benchmarks, and metrics in the report,
486	including projected cost savings to the state Medicaid program
487	during the following fiscal year.
488	(1) For the purposes of this section, the term:
489	(a) "Abuse" means:
490	1. Provider practices that are inconsistent with generally
491	accepted business or medical practices and that result in an
492	unnecessary cost to the Medicaid program or in reimbursement for
493	goods or services that are not medically necessary or that fail
494	to meet professionally recognized standards for health care.
495	2. Recipient practices that result in unnecessary cost to
496	the Medicaid program.
497	(b) "Complaint" means an allegation that fraud, abuse, or
498	an overpayment has occurred.
499	(c) "Fraud" means an intentional deception or
500	misrepresentation made by a person with the knowledge that the
501	deception results in unauthorized benefit to herself or himself
502	or another person. The term includes any act that constitutes
503	fraud under applicable federal or state law.
504	(d) "Medical necessity" or "medically necessary" means any
505	goods or services necessary to palliate the effects of a
506	terminal condition, or to prevent, diagnose, correct, cure,
507	alleviate, or preclude deterioration of a condition that
508	threatens life, causes pain or suffering, or results in illness
509	or infirmity, which goods or services are provided in accordance
510	with generally accepted standards of medical practice. For
511	purposes of determining Medicaid reimbursement, the agency is
512	the final arbiter of medical necessity. Determinations of
513	medical necessity must be made by a licensed physician employed
514	by or under contract with the agency and must be based upon
515	information available at the time the goods or services are
516	provided.
517	(e) "Overpayment" includes any amount that is not
518	authorized to be paid by the Medicaid program whether paid as a
519	result of inaccurate or improper cost reporting, improper
520	claiming, unacceptable practices, fraud, abuse, or mistake.
521	(f) "Person" means any natural person, corporation,
522	partnership, association, clinic, group, or other entity,
523	whether or not such person is enrolled in the Medicaid program
524	or is a provider of health care.
525	(2) The agency shall conduct, or cause to be conducted by
526	contract or otherwise, reviews, investigations, analyses,
527	audits, or any combination thereof, to determine possible fraud,
528	abuse, overpayment, or recipient neglect in the Medicaid program
529	and shall report the findings of any overpayments in audit
530	reports as appropriate. At least 5 percent of all audits shall
531	be conducted on a random basis. As part of its ongoing fraud
532	detection activities, the agency shall identify and monitor, by
533	contract or otherwise, patterns of overutilization of Medicaid
534	services based on state averages. The agency shall track
535	Medicaid provider prescription and billing patterns and evaluate
536	them against Medicaid medical necessity criteria and coverage
537	and limitation guidelines adopted by rule. Medical necessity
538	determination requires that service be consistent with symptoms
539	or confirmed diagnosis of illness or injury under treatment and
540	not in excess of the patient's needs. The agency shall conduct
541	reviews of provider exceptions to peer group norms and shall,
542	using statistical methodologies, provider profiling, and
543	analysis of billing patterns, detect and investigate abnormal or
544	unusual increases in billing or payment of claims for Medicaid
545	services and medically unnecessary provision of services.
546	(3) The agency may conduct, or may contract for,
547	prepayment review of provider claims to ensure cost-effective
548	purchasing; to ensure that billing by a provider to the agency
549	is in accordance with applicable provisions of all Medicaid
550	rules, regulations, handbooks, and policies and in accordance
551	with federal, state, and local law; and to ensure that
552	appropriate care is rendered to Medicaid recipients. Such
553	prepayment reviews may be conducted as determined appropriate by
554	the agency, without any suspicion or allegation of fraud, abuse,
555	or neglect, and may last for up to 1 year. Unless the agency has
556	reliable evidence of fraud, misrepresentation, abuse, or
557	neglect, claims shall be adjudicated for denial or payment
558	within 90 days after receipt of complete documentation by the
559	agency for review. If there is reliable evidence of fraud,
560	misrepresentation, abuse, or neglect, claims shall be
561	adjudicated for denial of payment within 180 days after receipt
562	of complete documentation by the agency for review.
563	(4) Any suspected criminal violation identified by the
564	agency must be referred to the Medicaid Fraud Control Unit of
565	the Office of the Attorney General for investigation. The agency
566	and the Attorney General shall enter into a memorandum of
567	understanding, which must include, but need not be limited to, a
568	protocol for regularly sharing information and coordinating
569	casework. The protocol must establish a procedure for the
570	referral by the agency of cases involving suspected Medicaid
571	fraud to the Medicaid Fraud Control Unit for investigation, and
572	the return to the agency of those cases where investigation
573	determines that administrative action by the agency is
574	appropriate. Offices of the Medicaid program integrity program
575	and the Medicaid Fraud Control Unit of the Department of Legal
576	Affairs, shall, to the extent possible, be collocated. The
577	agency and the Department of Legal Affairs shall periodically
578	conduct joint training and other joint activities designed to
579	increase communication and coordination in recovering
580	overpayments.
581	(5) A Medicaid provider is subject to having goods and
582	services that are paid for by the Medicaid program reviewed by
583	an appropriate peer-review organization designated by the
584	agency. The written findings of the applicable peer-review
585	organization are admissible in any court or administrative
586	proceeding as evidence of medical necessity or the lack thereof.
587	(6) Any notice required to be given to a provider under
588	this section is presumed to be sufficient notice if sent to the
589	address last shown on the provider enrollment file. It is the
590	responsibility of the provider to furnish and keep the agency
591	informed of the provider's current address. United States Postal
592	Service proof of mailing or certified or registered mailing of
593	such notice to the provider at the address shown on the provider
594	enrollment file constitutes sufficient proof of notice. Any
595	notice required to be given to the agency by this section must
596	be sent to the agency at an address designated by rule.
597	(7) When presenting a claim for payment under the Medicaid
598	program, a provider has an affirmative duty to supervise the
599	provision of, and be responsible for, goods and services claimed
600	to have been provided, to supervise and be responsible for
601	preparation and submission of the claim, and to present a claim
602	that is true and accurate and that is for goods and services
603	that:
604	(a) Have actually been furnished to the recipient by the
605	provider prior to submitting the claim.
606	(b) Are Medicaid-covered goods or services that are
607	medically necessary.
608	(c) Are of a quality comparable to those furnished to the
609	general public by the provider's peers.
610	(d) Have not been billed in whole or in part to a
611	recipient or a recipient's responsible party, except for such
612	copayments, coinsurance, or deductibles as are authorized by the
613	agency.
614	(e) Are provided in accord with applicable provisions of
615	all Medicaid rules, regulations, handbooks, and policies and in
616	accordance with federal, state, and local law.
617	(f) Are documented by records made at the time the goods
618	or services were provided, demonstrating the medical necessity
619	for the goods or services rendered. Medicaid goods or services
620	are excessive or not medically necessary unless both the medical
621	basis and the specific need for them are fully and properly
622	documented in the recipient's medical record.
623
624	The agency shall deny payment or require repayment for goods or
625	services that are not presented as required in this subsection.
626	(8) The agency shall not reimburse any person or entity
627	for any prescription for medications, medical supplies, or
628	medical services if the prescription was written by a physician
629	or other prescribing practitioner who is not enrolled in the
630	Medicaid program. This section does not apply:
631	(a) In instances involving bona fide emergency medical
632	conditions as determined by the agency;
633	(b) To a provider of medical services to a patient in a
634	hospital emergency department, hospital inpatient or outpatient
635	setting, or nursing home;
636	(c) To bona fide pro bono services by preapproved non-
637	Medicaid providers as determined by the agency;
638	(d) To prescribing physicians who are board-certified
639	specialists treating Medicaid recipients referred for treatment
640	by a treating physician who is enrolled in the Medicaid program;
641	(e) To prescriptions written for dually eligible Medicare
642	beneficiaries by an authorized Medicare provider who is not
643	enrolled in the Medicaid program;
644	(f) To other physicians who are not enrolled in the
645	Medicaid program but who provide a medically necessary service
646	or prescription not otherwise reasonably available from a
647	Medicaid-enrolled physician; or
648	(9) A Medicaid provider shall retain medical,
649	professional, financial, and business records pertaining to
650	services and goods furnished to a Medicaid recipient and billed
651	to Medicaid for a period of 6 5 years after the date of
652	furnishing such services or goods. The agency may investigate,
653	review, or analyze such records, which must be made available
654	during normal business hours. However, 24-hour notice must be
655	provided if patient treatment would be disrupted. The provider
656	is responsible for furnishing to the agency, and keeping the
657	agency informed of the location of, the provider's Medicaid-
658	related records. The authority of the agency to obtain Medicaid-
659	related records from a provider is neither curtailed nor limited
660	during a period of litigation between the agency and the
661	provider.
662	(10) Payments for the services of billing agents or
663	persons participating in the preparation of a Medicaid claim
664	shall not be based on amounts for which they bill nor based on
665	the amount a provider receives from the Medicaid program.
666	(11) The agency shall deny payment or require repayment
667	for inappropriate, medically unnecessary, or excessive goods or
668	services from the person furnishing them, the person under whose
669	supervision they were furnished, or the person causing them to
670	be furnished.
671	(12) The complaint and all information obtained pursuant
672	to an investigation of a Medicaid provider, or the authorized
673	representative or agent of a provider, relating to an allegation
674	of fraud, abuse, or neglect are confidential and exempt from the
675	provisions of s. 119.07(1):
676	(a) Until the agency takes final agency action with
677	respect to the provider and requires repayment of any
678	overpayment, or imposes an administrative sanction;
679	(b) Until the Attorney General refers the case for
680	criminal prosecution;
681	(c) Until 10 days after the complaint is determined
682	without merit; or
683	(d) At all times if the complaint or information is
684	otherwise protected by law.
685	(13) The agency shall immediately terminate participation
686	of a Medicaid provider in the Medicaid program and may seek
687	civil remedies or impose other administrative sanctions against
688	a Medicaid provider, if the provider or any principal, officer,
689	director, agent, managing employee, or affiliated person of the
690	provider, or any partner or shareholder having an ownership
691	interest in the provider equal to 5 percent or greater, has
692	been:
693	(a) Convicted of a criminal offense related to the
694	delivery of any health care goods or services, including the
695	performance of management or administrative functions relating
696	to the delivery of health care goods or services;
697	(b) Convicted of a criminal offense under federal law or
698	the law of any state relating to the practice of the provider's
699	profession; or
700	(c) Found by a court of competent jurisdiction to have
701	neglected or physically abused a patient in connection with the
702	delivery of health care goods or services.
703
704	If the agency determines a provider did not participate or
705	acquiesce in an offense specified in paragraph (a), paragraph
706	(b), or paragraph (c), termination will not be imposed. If the
707	agency effects a termination under this subsection, the agency
708	shall issue an immediate termination final order as provided in
709	subsection (16) pursuant to s. 120.569(2)(n).
710	(14) If the provider has been suspended or terminated from
711	participation in the Medicaid program or the Medicare program by
712	the Federal Government or any state, the agency must immediately
713	suspend or terminate, as appropriate, the provider's
714	participation in this state's Medicaid program for a period no
715	less than that imposed by the Federal Government or any other
716	state, and may not enroll such provider in this state's Medicaid
717	program while such foreign suspension or termination remains in
718	effect. The agency shall also immediately suspend or terminate,
719	as appropriate, a provider's participation in this state's
720	Medicaid program if the provider participated or acquiesced in
721	any action for which any principal, officer, director, agent,
722	managing employee, or affiliated person of the provider, or any
723	partner or shareholder having an ownership interest in the
724	provider equal to 5 percent or greater, was suspended or
725	terminated from participating in the Medicaid program or the
726	Medicare program by the Federal Government or any state. This
727	sanction is in addition to all other remedies provided by law.
728	If the agency suspends or terminates a provider's participation
729	in the state's Medicaid program under this subsection, the
730	agency shall issue an immediate suspension or immediate
731	termination order as provided in subsection (16).
732	(15) The agency shall seek a remedy provided by law,
733	including, but not limited to, any remedy provided in
734	subsections (13) and (16) and s. 812.035, if:
735	(a) The provider's license has not been renewed, or has
736	been revoked, suspended, or terminated, for cause, by the
737	licensing agency of any state;
738	(b) The provider has failed to make available or has
739	refused access to Medicaid-related records to an auditor,
740	investigator, or other authorized employee or agent of the
741	agency, the Attorney General, a state attorney, or the Federal
742	Government;
743	(c) The provider has not furnished or has failed to make
744	available such Medicaid-related records as the agency has found
745	necessary to determine whether Medicaid payments are or were due
746	and the amounts thereof;
747	(d) The provider has failed to maintain medical records
748	made at the time of service, or prior to service if prior
749	authorization is required, demonstrating the necessity and
750	appropriateness of the goods or services rendered;
751	(e) The provider is not in compliance with provisions of
752	Medicaid provider publications that have been adopted by
753	reference as rules in the Florida Administrative Code; with
754	provisions of state or federal laws, rules, or regulations; with
755	provisions of the provider agreement between the agency and the
756	provider; or with certifications found on claim forms or on
757	transmittal forms for electronically submitted claims that are
758	submitted by the provider or authorized representative, as such
759	provisions apply to the Medicaid program;
760	(f) The provider or person who ordered or prescribed the
761	care, services, or supplies has furnished, or ordered the
762	furnishing of, goods or services to a recipient which are
763	inappropriate, unnecessary, excessive, or harmful to the
764	recipient or are of inferior quality;
765	(g) The provider has demonstrated a pattern of failure to
766	provide goods or services that are medically necessary;
767	(h) The provider or an authorized representative of the
768	provider, or a person who ordered or prescribed the goods or
769	services, has submitted or caused to be submitted false or a
770	pattern of erroneous Medicaid claims;
771	(i) The provider or an authorized representative of the
772	provider, or a person who has ordered or prescribed the goods or
773	services, has submitted or caused to be submitted a Medicaid
774	provider enrollment application, a request for prior
775	authorization for Medicaid services, a drug exception request,
776	or a Medicaid cost report that contains materially false or
777	incorrect information;
778	(j) The provider or an authorized representative of the
779	provider has collected from or billed a recipient or a
780	recipient's responsible party improperly for amounts that should
781	not have been so collected or billed by reason of the provider's
782	billing the Medicaid program for the same service;
783	(k) The provider or an authorized representative of the
784	provider has included in a cost report costs that are not
785	allowable under a Florida Title XIX reimbursement plan, after
786	the provider or authorized representative had been advised in an
787	audit exit conference or audit report that the costs were not
788	allowable;
789	(l) The provider is charged by information or indictment
790	with fraudulent billing practices or an offense under subsection
791	(13). The sanction applied for this reason is limited to
792	suspension of the provider's participation in the Medicaid
793	program for the duration of the indictment unless the provider
794	is found guilty pursuant to the information or indictment;
795	(m) The provider or a person who has ordered or prescribed
796	the goods or services is found liable for negligent practice
797	resulting in death or injury to the provider's patient;
798	(n) The provider fails to demonstrate that it had
799	available during a specific audit or review period sufficient
800	quantities of goods, or sufficient time in the case of services,
801	to support the provider's billings to the Medicaid program;
802	(o) The provider has failed to comply with the notice and
803	reporting requirements of s. 409.907;
804	(p) The agency has received reliable information of
805	patient abuse or neglect or of any act prohibited by s. 409.920;
806	or
807	(q) The provider has failed to comply with an agreed-upon
808	repayment schedule.
809
810	A provider is subject to sanctions for violations of this
811	subsection as the result of actions or inactions of the
812	provider, or actions or inactions of any principal, officer,
813	director, agent, managing employee, or affiliated person of the
814	provider, or any partner or shareholder having an ownership
815	interest in the provider equal to 5 percent or greater, in which
816	the provider participated or acquiesced. If the agency suspends
817	or terminates a provider under this subsection, the agency shall
818	issue an immediate suspension or immediate termination order as
819	provided in subsection (16).
820	(16) The agency shall impose any of the following
821	sanctions or disincentives on a provider or a person for any of
822	the acts described in subsection (15):
823	(a) Suspension for a specific period of time of not more
824	than 1 year. Suspension shall preclude participation in the
825	Medicaid program, which includes any action that results in a
826	claim for payment to the Medicaid program as a result of
827	furnishing, supervising a person who is furnishing, or causing a
828	person to furnish goods or services.
829	(b) Termination for a specific period of time of from more
830	than 1 year to 20 years. Termination shall preclude
831	participation in the Medicaid program, which includes any action
832	that results in a claim for payment to the Medicaid program as a
833	result of furnishing, supervising a person who is furnishing, or
834	causing a person to furnish goods or services.
835	(c) Imposition of a fine of up to $5,000 for each
836	violation. Each day that an ongoing violation continues, such as
837	refusing to furnish Medicaid-related records or refusing access
838	to records, is considered, for the purposes of this section, to
839	be a separate violation. Each instance of improper billing of a
840	Medicaid recipient; each instance of including an unallowable
841	cost on a hospital or nursing home Medicaid cost report after
842	the provider or authorized representative has been advised in an
843	audit exit conference or previous audit report of the cost
844	unallowability; each instance of furnishing a Medicaid recipient
845	goods or professional services that are inappropriate or of
846	inferior quality as determined by competent peer judgment; each
847	instance of knowingly submitting a materially false or erroneous
848	Medicaid provider enrollment application, request for prior
849	authorization for Medicaid services, drug exception request, or
850	cost report; each instance of inappropriate prescribing of drugs
851	for a Medicaid recipient as determined by competent peer
852	judgment; and each false or erroneous Medicaid claim leading to
853	an overpayment to a provider is considered, for the purposes of
854	this section, to be a separate violation.
855	(d) Immediate suspension, if the agency has received
856	information of patient abuse or neglect, or of any act
857	prohibited by s. 409.920, or any conduct listed in subsection
858	(13) or subsection (14). Upon suspension, the agency must issue
859	an immediate suspension final order, which shall state that the
860	agency has reasonable cause to believe that the provider,
861	person, or entity named is engaging in or has engaged in patient
862	abuse or neglect, any act prohibited by s. 409.920, or any
863	conduct listed in subsection (13) or subsection (14). The order
864	shall provide notice of administrative hearing rights under ss.
865	120.569 and 120.57 and is effective immediately upon notice to
866	the provider, person, or entity under s. 120.569(2)(n).
867	(e) Immediate termination, if the agency has received
868	information of a conviction of patient abuse or neglect, any act
869	prohibited by s. 409.920, or any conduct listed in subsection
870	(13) or subsection (14). Upon termination, the agency must issue
871	an immediate termination order, which shall state that the
872	agency has reasonable cause to believe that the provider,
873	person, or entity named has been convicted of patient abuse or
874	neglect, any act prohibited by s. 409.920, or any conduct listed
875	in subsection (13) or subsection (14). The termination order
876	shall provide notice of administrative hearing rights under ss.
877	120.569 and 120.57 and is effective immediately upon notice to
878	the provider, person, or entity.
879	(f)(e) A fine, not to exceed $10,000, for a violation of
880	paragraph (15)(i).
881	(g)(f) Imposition of liens against provider assets,
882	including, but not limited to, financial assets and real
883	property, not to exceed the amount of fines or recoveries
884	sought, upon entry of an order determining that such moneys are
885	due or recoverable.
886	(h)(g) Prepayment reviews of claims for a specified period
887	of time.
888	(i)(h) Comprehensive followup reviews of providers every 6
889	months to ensure that they are billing Medicaid correctly.
890	(j)(i) Corrective-action plans that would remain in effect
891	for providers for up to 3 years and that would be monitored by
892	the agency every 6 months while in effect.
893	(k)(j) Other remedies as permitted by law to effect the
894	recovery of a fine or overpayment.
895
896	The Secretary of Health Care Administration may make a
897	determination that imposition of a sanction or disincentive is
898	not in the best interest of the Medicaid program, in which case
899	a sanction or disincentive shall not be imposed.
900	(17) In determining the appropriate administrative
901	sanction to be applied, or the duration of any suspension or
902	termination, the agency shall consider:
903	(a) The seriousness and extent of the violation or
904	violations.
905	(b) Any prior history of violations by the provider
906	relating to the delivery of health care programs which resulted
907	in either a criminal conviction or in administrative sanction or
908	penalty.
909	(c) Evidence of continued violation within the provider's
910	management control of Medicaid statutes, rules, regulations, or
911	policies after written notification to the provider of improper
912	practice or instance of violation.
913	(d) The effect, if any, on the quality of medical care
914	provided to Medicaid recipients as a result of the acts of the
915	provider.
916	(e) Any action by a licensing agency respecting the
917	provider in any state in which the provider operates or has
918	operated.
919	(f) The apparent impact on access by recipients to
920	Medicaid services if the provider is suspended or terminated, in
921	the best judgment of the agency.
922
923	The agency shall document the basis for all sanctioning actions
924	and recommendations.
925	(18) The agency may take action to sanction, suspend, or
926	terminate a particular provider working for a group provider,
927	and may suspend or terminate Medicaid participation at a
928	specific location, rather than or in addition to taking action
929	against an entire group.
930	(19) The agency shall establish a process for conducting
931	followup reviews of a sampling of providers who have a history
932	of overpayment under the Medicaid program. This process must
933	consider the magnitude of previous fraud or abuse and the
934	potential effect of continued fraud or abuse on Medicaid costs.
935	(20) In making a determination of overpayment to a
936	provider, the agency must use accepted and valid auditing,
937	accounting, analytical, statistical, or peer-review methods, or
938	combinations thereof. Appropriate statistical methods may
939	include, but are not limited to, sampling and extension to the
940	population, parametric and nonparametric statistics, tests of
941	hypotheses, and other generally accepted statistical methods.
942	Appropriate analytical methods may include, but are not limited
943	to, reviews to determine variances between the quantities of
944	products that a provider had on hand and available to be
945	purveyed to Medicaid recipients during the review period and the
946	quantities of the same products paid for by the Medicaid program
947	for the same period, taking into appropriate consideration sales
948	of the same products to non-Medicaid customers during the same
949	period. In meeting its burden of proof in any administrative or
950	court proceeding, the agency may introduce the results of such
951	statistical methods as evidence of overpayment.
952	(21) When making a determination that an overpayment has
953	occurred, the agency shall prepare and issue an audit report to
954	the provider showing the calculation of overpayments.
955	(22) The audit report, supported by agency work papers,
956	showing an overpayment to a provider constitutes evidence of the
957	overpayment. A provider may not present or elicit testimony,
958	either on direct examination or cross-examination in any court
959	or administrative proceeding, regarding the purchase or
960	acquisition by any means of drugs, goods, or supplies; sales or
961	divestment by any means of drugs, goods, or supplies; or
962	inventory of drugs, goods, or supplies, unless such acquisition,
963	sales, divestment, or inventory is documented by written
964	invoices, written inventory records, or other competent written
965	documentary evidence maintained in the normal course of the
966	provider's business. Notwithstanding the applicable rules of
967	discovery, all documentation that will be offered as evidence at
968	an administrative hearing on a Medicaid overpayment must be
969	exchanged by all parties at least 14 days before the
970	administrative hearing or must be excluded from consideration.
971	(23)(a) In an audit or investigation of a violation
972	committed by a provider which is conducted pursuant to this
973	section, the agency is entitled to recover all investigative,
974	legal, and expert witness costs if the agency's findings were
975	not contested by the provider or, if contested, the agency
976	ultimately prevailed.
977	(b) The agency has the burden of documenting the costs,
978	which include salaries and employee benefits and out-of-pocket
979	expenses. The amount of costs that may be recovered must be
980	reasonable in relation to the seriousness of the violation and
981	must be set taking into consideration the financial resources,
982	earning ability, and needs of the provider, who has the burden
983	of demonstrating such factors.
984	(c) The provider may pay the costs over a period to be
985	determined by the agency if the agency determines that an
986	extreme hardship would result to the provider from immediate
987	full payment. Any default in payment of costs may be collected
988	by any means authorized by law.
989	(24) If the agency imposes an administrative sanction
990	pursuant to subsection (13), subsection (14), or subsection
991	(15), except paragraphs (15)(e) and (o), upon any provider or
992	any principal, officer, director, agent, managing employee, or
993	affiliated person of the provider who is regulated by another
994	state entity, the agency shall notify that other entity of the
995	imposition of the sanction within 5 business days. Such
996	notification must include the provider's or person's name and
997	license number and the specific reasons for sanction.
998	(25)(a) The agency shall withhold Medicaid payments, in
999	whole or in part, to a provider upon receipt of reliable
1000	evidence that the circumstances giving rise to the need for a
1001	withholding of payments involve fraud, willful
1002	misrepresentation, or abuse under the Medicaid program, or a
1003	crime committed while rendering goods or services to Medicaid
1004	recipients. If the provider is not paid within 14 days after the
1005	provider receives such evidence, interest shall accrue at a rate
1006	of 10 percent a year. If it is determined that fraud, willful
1007	misrepresentation, abuse, or a crime did not occur, the payments
1008	withheld must be paid to the provider within 14 days after such
1009	determination with interest at the rate of 10 percent a year.
1010	Any money withheld in accordance with this paragraph shall be
1011	placed in a suspended account, readily accessible to the agency,
1012	so that any payment ultimately due the provider shall be made
1013	within 14 days.
1014	(b) The agency shall deny payment, or require repayment,
1015	if the goods or services were furnished, supervised, or caused
1016	to be furnished by a person who has been convicted of a crime
1017	under subsection (13) or who has been suspended or terminated
1018	from the Medicaid program or Medicare program by the Federal
1019	Government or any state.
1020	(c) Overpayments owed to the agency bear interest at the
1021	rate of 10 percent per year from the date of determination of
1022	the overpayment by the agency, and payment arrangements
1023	regarding overpayments and fines must be made within 35 days
1024	after the date of the termination or suspension order at the
1025	conclusion of legal proceedings. A provider who does not enter
1026	into or adhere to an agreed-upon repayment schedule may be
1027	terminated by the agency for nonpayment or partial payment.
1028	(d) The agency, upon entry of a final agency order, a
1029	judgment or order of a court of competent jurisdiction, or a
1030	stipulation or settlement, may collect the moneys owed by all
1031	means allowable by law, including, but not limited to, notifying
1032	any fiscal intermediary of Medicare benefits that the state has
1033	a superior right of payment. Upon receipt of such written
1034	notification, the Medicare fiscal intermediary shall remit to
1035	the state the sum claimed.
1036	(e) The agency may institute amnesty programs to allow
1037	Medicaid providers the opportunity to voluntarily repay
1038	overpayments. The agency may adopt rules to administer such
1039	programs.
1040	(26) The agency may impose administrative sanctions
1041	against a Medicaid recipient, or the agency may seek any other
1042	remedy provided by law, including, but not limited to, the
1043	remedies provided in s. 812.035, if the agency finds that a
1044	recipient has engaged in solicitation in violation of s. 409.920
1045	or that the recipient has otherwise abused the Medicaid program.
1046	(27) When the Agency for Health Care Administration has
1047	made a probable cause determination and alleged that an
1048	overpayment to a Medicaid provider has occurred, the agency,
1049	after notice to the provider, shall:
1050	(a) Withhold, and continue to withhold during the pendency
1051	of an administrative hearing pursuant to chapter 120, any
1052	medical assistance reimbursement payments until such time as the
1053	overpayment is recovered, unless within 30 days after receiving
1054	notice thereof the provider:
1055	1. Makes repayment in full; or
1056	2. Establishes a repayment plan that is satisfactory to
1057	the Agency for Health Care Administration.
1058	(b) Withhold, and continue to withhold during the pendency
1059	of an administrative hearing pursuant to chapter 120, medical
1060	assistance reimbursement payments if the terms of a repayment
1061	plan are not adhered to by the provider.
1062	(28) Venue for all Medicaid program integrity overpayment
1063	cases shall lie in Leon County, at the discretion of the agency.
1064	(29) Notwithstanding other provisions of law, the agency
1065	and the Medicaid Fraud Control Unit of the Department of Legal
1066	Affairs may review a provider's Medicaid-related and non-
1067	Medicaid-related records in order to determine the total output
1068	of a provider's practice to reconcile quantities of goods or
1069	services billed to Medicaid with quantities of goods or services
1070	used in the provider's total practice.
1071	(30) The agency shall terminate a provider's participation
1072	in the Medicaid program if the provider fails to reimburse an
1073	overpayment or fine that has been determined by termination or
1074	suspension final order, not subject to further appeal, within 35
1075	days after the date of the termination or suspension final
1076	order, unless the provider and the agency have entered into a
1077	repayment agreement.
1078	(31) If a provider requests an administrative hearing
1079	pursuant to chapter 120, such hearing must be conducted within
1080	90 days following assignment of an administrative law judge,
1081	absent exceptionally good cause shown as determined by the
1082	administrative law judge or hearing officer. Upon issuance of a
1083	termination or suspension final order, the outstanding balance
1084	of the amount determined to constitute the overpayment or fine
1085	shall become due. If a provider fails to make payments in full,
1086	fails to enter into a satisfactory repayment plan, or fails to
1087	comply with the terms of a repayment plan or settlement
1088	agreement, the agency shall withhold medical assistance
1089	reimbursement payments until the amount due is paid in full.
1090	(32) Duly authorized agents and employees of the agency
1091	shall have the power to inspect, during normal business hours,
1092	the records of any pharmacy, wholesale establishment, or
1093	manufacturer, or any other place in which drugs and medical
1094	supplies are manufactured, packed, packaged, made, stored, sold,
1095	or kept for sale, for the purpose of verifying the amount of
1096	drugs and medical supplies ordered, delivered, or purchased by a
1097	provider. The agency shall provide at least 2 business days'
1098	prior notice of any such inspection. The notice must identify
1099	the provider whose records will be inspected, and the inspection
1100	shall include only records specifically related to that
1101	provider.
1102	(33) In accordance with federal law, Medicaid recipients
1103	convicted of a crime pursuant to 42 U.S.C. s. 1320a-7b may be
1104	limited, restricted, or suspended from Medicaid eligibility for
1105	a period not to exceed 1 year, as determined by the agency head
1106	or designee.
1107	(34) To deter fraud and abuse in the Medicaid program, the
1108	agency may limit the number of Schedule II and Schedule III
1109	refill prescription claims submitted from a pharmacy provider.
1110	The agency shall limit the allowable amount of reimbursement of
1111	prescription refill claims for Schedule II and Schedule III
1112	pharmaceuticals if the agency or the Medicaid Fraud Control Unit
1113	determines that the specific prescription refill was not
1114	requested by the Medicaid recipient or authorized representative
1115	for whom the refill claim is submitted or was not prescribed by
1116	the recipient's medical provider or physician. Any such refill
1117	request must be consistent with the original prescription.
1118	(35) The Office of Program Policy Analysis and Government
1119	Accountability shall provide a report to the President of the
1120	Senate and the Speaker of the House of Representatives on a
1121	biennial basis, beginning January 31, 2006, on the agency's
1122	efforts to prevent, detect, and deter, as well as recover funds
1123	lost to, fraud and abuse in the Medicaid program.
1124	(36) At least three times a year, the agency shall provide
1125	to each Medicaid recipient or his or her representative an
1126	explanation of benefits in the form of a letter that is mailed
1127	to the most recent address of the recipient on the record with
1128	the Department of Children and Family Services. The explanation
1129	of benefits must include the patient's name, the name of the
1130	health care provider and the address of the location where the
1131	service was provided, a description of all services billed to
1132	Medicaid in terminology that should be understood by a
1133	reasonable person, and information on how to report
1134	inappropriate or incorrect billing to the agency or other law
1135	enforcement entities for review or investigation. At least once
1136	a year, the letter also must include information on how to
1137	report criminal Medicaid fraud, the Medicaid Fraud Control
1138	Unit's toll-free hotline number, and information about the
1139	rewards available under s. 409.9203. The explanation of benefits
1140	may not be mailed for Medicaid independent laboratory services
1141	as described in s. 409.905(7) or for Medicaid certified match
1142	services as described in ss. 409.9071 and 1011.70.
1143	(37) The agency shall post on its website a current list
1144	of each Medicaid provider, including any principal, officer,
1145	director, agent, managing employee, or affiliated person of the
1146	provider, or any partner or shareholder having an ownership
1147	interest in the provider equal to 5 percent or greater, who has
1148	been terminated for cause from the Medicaid program or
1149	sanctioned under this section. The list must be searchable by a
1150	variety of search parameters and provide for the creation of
1151	formatted lists that may be printed or imported into other
1152	applications, including spreadsheets. The agency shall update
1153	the list at least monthly.
1154	(38) In order to improve the detection of health care
1155	fraud, use technology to prevent and detect fraud, and maximize
1156	the electronic exchange of health care fraud information, the
1157	agency shall:
1158	(a) Compile, maintain, and publish on its website a
1159	detailed list of all state and federal databases that contain
1160	health care fraud information and update the list at least
1161	biannually;
1162	(b) Develop a strategic plan to connect all databases that
1163	contain health care fraud information to facilitate the
1164	electronic exchange of health information between the agency,
1165	the Department of Health, the Department of Law Enforcement, and
1166	the Attorney General's Office. The plan must include recommended
1167	standard data formats, fraud identification strategies, and
1168	specifications for the technical interface between state and
1169	federal health care fraud databases;
1170	(c) Monitor innovations in health information technology,
1171	specifically as it pertains to Medicaid fraud prevention and
1172	detection; and
1173	(d) Periodically publish policy briefs that highlight
1174	available new technology to prevent or detect health care fraud
1175	and projects implemented by other states, the private sector, or
1176	the Federal Government which use technology to prevent or detect
1177	health care fraud.
1178	Section 7. Subsection (5) is added to section 409.9203,
1179	Florida Statutes, to read:
1180	409.9203 Rewards for reporting Medicaid fraud.-
1181	(5) An employee of the Agency for Health Care
1182	Administration, the Department of Legal Affairs, the Department
1183	of Health, or the Department of Law Enforcement whose job
1184	responsibilities include the prevention, detection, and
1185	prosecution of Medicaid fraud is not eligible to receive a
1186	reward under this section.
1187	Section 8. Subsection (8) is added to section 456.001,
1188	Florida Statutes, to read:
1189	456.001 Definitions.-As used in this chapter, the term:
1190	(8) "Affiliate" or "affiliated person" means any person
1191	who directly or indirectly manages, controls, or oversees the
1192	operation of a corporation or other business entity, regardless
1193	of whether that person is a partner, shareholder, owner,
1194	officer, director, or agent of the entity.
1195	Section 9. Subsections (7) through (11) of section
1196	456.041, Florida Statutes, are renumbered as subsections (8)
1197	through (12), respectively, a new subsection (7) is added to
1198	that section, and paragraph (c) of subsection (1) and
1199	subsections (2) and (3) of that section are amended, to read:
1200	456.041 Practitioner profile; creation.-
1201	(1)
1202	(c) Within 30 calendar days after receiving an update of
1203	information required for the practitioner's profile, the
1204	department shall update the practitioner's profile in accordance
1205	with the requirements of subsection (9) (7).
1206	(2) Beginning July 1, 2010, on the profile published under
1207	subsection (1), the department shall include indicate if the
1208	information provided under s. 456.039(1)(a)7. or s.
1209	456.0391(1)(a)7. and indicate if the information is or is not
1210	corroborated by a criminal history records check conducted
1211	according to this subsection. The department must include in
1212	each practitioner's profile the following statement: "The
1213	criminal history information, if any exists, may be incomplete.
1214	Federal criminal history information is not available to the
1215	public." The department, or the board having regulatory
1216	authority over the practitioner acting on behalf of the
1217	department, shall investigate any information received by the
1218	department or the board.
1219	(3) Beginning July 1, 2010, the department shall include
1220	in each practitioner's profile any administrative complaint
1221	filed with the department against the practitioner in which
1222	probable cause has been found and the status of the complaint.
1223	The Department of Health shall include in each practitioner's
1224	practitioner profile that criminal information that directly
1225	relates to the practitioner's ability to competently practice
1226	his or her profession. The department must include in each
1227	practitioner's practitioner profile the following statement:
1228	"The criminal history information, if any exists, may be
1229	incomplete; federal criminal history information is not
1230	available to the public." The department shall provide in each
1231	practitioner profile, for every final disciplinary action taken
1232	against the practitioner, an easy-to-read narrative description
1233	that explains the administrative complaint filed against the
1234	practitioner and the final disciplinary action imposed on the
1235	practitioner. The department shall include a hyperlink to each
1236	final order listed in its website report of dispositions of
1237	recent disciplinary actions taken against practitioners.
1238	(7) Beginning July 1, 2010, the department shall include
1239	in each practitioner's profile detailed information about each
1240	arrest related to that practitioner. The department must include
1241	in each practitioner's profile the following statement: "The
1242	arrest information, if any exists, may be incomplete."
1243	Section 10. Paragraph (kk) of subsection (1) of section
1244	456.072, Florida Statutes, is amended to read:
1245	456.072 Grounds for discipline; penalties; enforcement.-
1246	(1) The following acts shall constitute grounds for which
1247	the disciplinary actions specified in subsection (2) may be
1248	taken:
1249	(kk) Being terminated from the state Medicaid program
1250	pursuant to s. 409.913 or, any other state Medicaid program, or
1251	excluded from the federal Medicare program, unless eligibility
1252	to participate in the program from which the practitioner was
1253	terminated has been restored.
1254	Section 11. Subsection (13) of section 456.073, Florida
1255	Statutes, is amended to read:
1256	456.073 Disciplinary proceedings.-Disciplinary proceedings
1257	for each board shall be within the jurisdiction of the
1258	department.
1259	(13) Notwithstanding any provision of law to the contrary,
1260	an administrative complaint against a licensee shall be filed
1261	within 6 years after the time of the incident or occurrence
1262	giving rise to the complaint against the licensee. If such
1263	incident or occurrence involved fraud related to the Medicaid
1264	program, criminal actions, diversion of controlled substances,
1265	sexual misconduct, or impairment by the licensee, this
1266	subsection does not apply to bar initiation of an investigation
1267	or filing of an administrative complaint beyond the 6-year
1268	timeframe. In those cases covered by this subsection in which it
1269	can be shown that fraud, concealment, or intentional
1270	misrepresentation of fact prevented the discovery of the
1271	violation of law, the period of limitations is extended forward,
1272	but in no event to exceed 12 years after the time of the
1273	incident or occurrence.
1274	Section 12. Subsection (1) of section 456.074, Florida
1275	Statutes, is amended to read:
1276	456.074 Certain health care practitioners; immediate
1277	suspension of license.-
1278	(1) The department shall issue an emergency order
1279	suspending the license of any person licensed in a profession as
1280	defined in chapter 456 under chapter 458, chapter 459, chapter
1281	460, chapter 461, chapter 462, chapter 463, chapter 464, chapter
1282	465, chapter 466, or chapter 484 who pleads guilty to, is
1283	convicted or found guilty of, or who enters a plea of nolo
1284	contendere to, regardless of adjudication, to:
1285	(a) A felony under chapter 409, chapter 812, chapter 817,
1286	or chapter 893, chapter 895, chapter 896, or under 21 U.S.C. ss.
1287	801-970, or under 42 U.S.C. ss. 1395-1396; or
1288	(b) A misdemeanor or felony under 18 U.S.C. s. 669, ss.
1289	285-287, s. 371, s. 1001, s. 1035, s. 1341, s. 1343, s. 1347, s.
1290	1349, or s. 1518 or 42 U.S.C. ss. 1320a-7b, relating to the
1291	Medicaid program.
1292	Section 13. This act shall take effect July 1, 2010.

CODING: Words stricken are deletions; words underlined are additions.