SB1330 EngrossedLRB098 02585 KTG 32689 b

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1    complete records, including, but not limited to, records
2    relating to recipients under the medical assistance
3    program for the most recent 6 years, in accordance with
4    Section 140.28 of Title 89 of the Illinois Administrative
5    Code, and other information for the purpose of audits,
6    investigations, or other program integrity functions,
7    after reasonable written request by the Inspector General;
8    this subsection (E) does not require vendors to make
9    available the medical records of patients for whom services
10    are not reimbursed under this Code or to provide access to
11    medical records more than 6 years old; (iv) when the vendor
12    has knowingly made, or caused to be made, any false
13    statement or representation of a material fact in
14    connection with the administration of the medical
15    assistance program; or (v) when the vendor previously
16    rendered services while terminated, suspended, or excluded
17    from participation in the medical assistance program or
18    while terminated or excluded from participation in another
19    state or federal medical assistance or health care program.
20        (2) Notwithstanding any other provision of law, if a
21    vendor has the same taxpayer identification number
22    (assigned under Section 6109 of the Internal Revenue Code
23    of 1986) as is assigned to a vendor with past-due financial
24    obligations to the Illinois Department, the Illinois
25    Department may make any necessary adjustments to payments
26    to that vendor in order to satisfy any past-due

 

 

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1    obligations, regardless of whether the vendor is assigned a
2    different billing number under the medical assistance
3    program.
4    If the Illinois Department establishes through an
5administrative hearing that the overpayments resulted from the
6vendor or alternate payee knowingly making, using, or causing
7to be made or used, a false record or statement to obtain
8payment or other benefit from the medical assistance program
9under Article V, the Department may recover interest on the
10amount of the payment or other benefit at the rate of 5% per
11annum. In addition to any other penalties that may be
12prescribed by law, such a vendor or alternate payee shall be
13subject to civil penalties consisting of an amount not to
14exceed 3 times the amount of payment or other benefit resulting
15from each such false record or statement, and the sum of $2,000
16for each such false record or statement for payment or other
17benefit. For purposes of this paragraph, "knowingly" means that
18a vendor or alternate payee with respect to information: (i)
19has actual knowledge of the information, (ii) acts in
20deliberate ignorance of the truth or falsity of the
21information, or (iii) acts in reckless disregard of the truth
22or falsity of the information. No proof of specific intent to
23defraud is required.
24    (E-5) Civil monetary penalties.
25        (1) As used in this subsection (E-5):
26            (a) "Knowingly" means that a person, with respect

 

 

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

 

 

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

 

 

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

 

 

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1        other individual from the hospital;
2            (d) in the case of a person who is not an
3        organization, agency, or other entity, is excluded
4        from participating in the medical assistance program
5        or a federal or state health care program and who, at
6        the time of a violation of this subsection (E-5):
7                (i) retains a direct or indirect ownership or
8            control interest in an entity that is
9            participating in the medical assistance program or
10            a federal or state health care program, and who
11            knows or should know of the action constituting the
12            basis for the exclusion; or
13                (ii) is an officer or managing employee of such
14            an entity;
15            (e) offers or transfers remuneration to any
16        individual eligible for benefits under the medical
17        assistance program that such person knows or should
18        know is likely to influence such individual to order or
19        receive from a particular vendor, provider,
20        practitioner, or supplier any item or service for which
21        payment may be made, in whole or in part, under the
22        medical assistance program;
23            (f) arranges or contracts (by employment or
24        otherwise) with an individual or entity that the person
25        knows or should know is excluded from participation in
26        the medical assistance program or a federal or state

 

 

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1        health care program, for the provision of items or
2        services for which payment may be made under such a
3        program;
4            (g) commits an act described in subsection (b) or
5        (c) of Section 8A-3;
6            (h) knowingly makes, uses, or causes to be made or
7        used, a false record or statement material to a false
8        or fraudulent claim for payment for items and services
9        furnished under the medical assistance program;
10            (i) fails to grant timely access, upon reasonable
11        request (as defined by the Department by rule), to the
12        Inspector General, for the purpose of audits,
13        investigations, evaluations, or other statutory
14        functions of the Inspector General of the Department;
15            (j) orders or prescribes a medical or other item or
16        service during a period in which the person was
17        excluded from the medical assistance program or a
18        federal or state health care program, in the case where
19        the person knows or should know that a claim for such
20        medical or other item or service will be made under
21        such a program;
22            (k) knowingly makes or causes to be made any false
23        statement, omission, or misrepresentation of a
24        material fact in any application, bid, or contract to
25        participate or enroll as a vendor or provider of
26        services or a supplier under the medical assistance

 

 

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

 

 

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1    assessment of not more than 3 times the total amount
2    claimed for each item or service for which payment was made
3    based upon the application, bid, or contract containing the
4    false statement, omission, or misrepresentation of a
5    material fact).
6        (3) In addition, the Director or his or her designee
7    may make a determination in the same proceeding to exclude,
8    terminate, suspend, or bar the person from participation in
9    the medical assistance program.
10        (4) The Illinois Department may seek the civil monetary
11    penalties and exclusion, termination, suspension, or
12    barment identified in this subsection (E-5). Prior to the
13    imposition of any penalties or sanctions, the affected
14    person shall be afforded an opportunity for a hearing after
15    reasonable notice. The Department shall establish hearing
16    procedures by rule.
17        (5) Any final order, decision, or other determination
18    made, issued, or executed by the Director under the
19    provisions of this subsection (E-5), whereby a person is
20    aggrieved, shall be subject to review in accordance with
21    the provisions of the Administrative Review Law, and the
22    rules adopted pursuant thereto, which shall apply to and
23    govern all proceedings for the judicial review of final
24    administrative decisions of the Director.
25        (6) (a) If a person has received an overpayment, the
26    person shall:

 

 

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1            (i) report and return the overpayment to the
2        Department at the correct address; and
3            (ii) notify the Department in writing of the reason
4        for the overpayment.
5        (b) An overpayment must be reported and returned under
6    subparagraph (a) by the later of:
7            (i) the date which is 60 days after the date on
8        which the overpayment was identified; or
9            (ii) the date any corresponding cost report is due,
10        if applicable.
11    (F) The Illinois Department may withhold payments to any
12vendor or alternate payee prior to or during the pendency of
13any audit or proceeding under this Section, and through the
14pendency of any administrative appeal or administrative review
15by any court proceeding. The Illinois Department shall state by
16rule with as much specificity as practicable the conditions
17under which payments will not be withheld under this Section.
18Payments may be denied for bills submitted with service dates
19occurring during the pendency of a proceeding, after a final
20decision has been rendered, or after the conclusion of any
21administrative appeal, where the final administrative decision
22is to terminate, exclude, or suspend eligibility to participate
23in the medical assistance program. The Illinois Department
24shall state by rule with as much specificity as practicable the
25conditions under which payments will not be denied for such
26bills. The Illinois Department shall state by rule a process

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1    default and set a new hearing date upon a petition filed at
2    any time (i) if the petitioner's failure to appear at the
3    hearing was for good cause, or (ii) if the petitioner
4    established that the Department did not provide proper
5    service of process. If any judgment is set aside pursuant
6    to this paragraph (5), the hearing officer shall have
7    authority to enter an order extinguishing any lien which
8    has been recorded for any debt due and owing the Illinois
9    Department as a result of the vacated default judgment.
10    (G) The provisions of the Administrative Review Law, as now
11or hereafter amended, and the rules adopted pursuant thereto,
12shall apply to and govern all proceedings for the judicial
13review of final administrative decisions of the Illinois
14Department under this Section. The term "administrative
15decision" is defined as in Section 3-101 of the Code of Civil
16Procedure.
17    (G-5) Vendors who pose a risk of fraud, waste, abuse, or
18harm.
19        (1) Notwithstanding any other provision in this
20    Section, the Department may terminate, suspend, or exclude
21    vendors who pose a risk of fraud, waste, abuse, or harm
22    from participation in the medical assistance program prior
23    to an evidentiary hearing but after reasonable notice and
24    opportunity to respond as established by the Department by
25    rule.
26        (2) Vendors who pose a risk of fraud, waste, abuse, or

 

 

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1    harm shall submit to a fingerprint-based criminal
2    background check on current and future information
3    available in the State system and current information
4    available through the Federal Bureau of Investigation's
5    system by submitting all necessary fees and information in
6    the form and manner prescribed by the Department of State
7    Police. The following individuals shall be subject to the
8    check:
9            (A) In the case of a vendor that is a corporation,
10        every shareholder who owns, directly or indirectly, 5%
11        or more of the outstanding shares of the corporation.
12            (B) In the case of a vendor that is a partnership,
13        every partner.
14            (C) In the case of a vendor that is a sole
15        proprietorship, the sole proprietor.
16            (D) Each officer or manager of the vendor.
17        Each such vendor shall be responsible for payment of
18    the cost of the criminal background check.
19        (3) Vendors who pose a risk of fraud, waste, abuse, or
20    harm may be required to post a surety bond. The Department
21    shall establish, by rule, the criteria and requirements for
22    determining when a surety bond must be posted and the value
23    of the bond.
24        (4) The Department, or its agents, may refuse to accept
25    requests for authorization from specific vendors who pose a
26    risk of fraud, waste, abuse, or harm, including

 

 

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

 

 

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

 

 

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1determine whether to recommend to the Director that the
2vendor's medical assistance program participation be denied,
3terminated, suspended, placed on provisional status, or
4reinstated. In the hearing, any evidence relevant to the vendor
5constituting an immediate danger to the public may be
6introduced against such vendor; provided, however, that the
7vendor, or his or her counsel, shall have the opportunity to
8discredit, impeach, and submit evidence rebutting such
9evidence.
10    (H) Nothing contained in this Code shall in any way limit
11or otherwise impair the authority or power of any State agency
12responsible for licensing of vendors.
13    (I) Based on a finding of noncompliance on the part of a
14nursing home with any requirement for certification under Title
15XVIII or XIX of the Social Security Act (42 U.S.C. Sec. 1395 et
16seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois Department
17may impose one or more of the following remedies after notice
18to the facility:
19        (1) Termination of the provider agreement.
20        (2) Temporary management.
21        (3) Denial of payment for new admissions.
22        (4) Civil money penalties.
23        (5) Closure of the facility in emergency situations or
24    transfer of residents, or both.
25        (6) State monitoring.
26        (7) Denial of all payments when the U.S. Department of

 

 

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1    Health and Human Services has imposed this sanction.
2    The Illinois Department shall by rule establish criteria
3governing continued payments to a nursing facility subsequent
4to termination of the facility's provider agreement if, in the
5sole discretion of the Illinois Department, circumstances
6affecting the health, safety, and welfare of the facility's
7residents require those continued payments. The Illinois
8Department may condition those continued payments on the
9appointment of temporary management, sale of the facility to
10new owners or operators, or other arrangements that the
11Illinois Department determines best serve the needs of the
12facility's residents.
13    Except in the case of a facility that has a right to a
14hearing on the finding of noncompliance before an agency of the
15federal government, a facility may request a hearing before a
16State agency on any finding of noncompliance within 60 days
17after the notice of the intent to impose a remedy. Except in
18the case of civil money penalties, a request for a hearing
19shall not delay imposition of the penalty. The choice of
20remedies is not appealable at a hearing. The level of
21noncompliance may be challenged only in the case of a civil
22money penalty. The Illinois Department shall provide by rule
23for the State agency that will conduct the evidentiary
24hearings.
25    The Illinois Department may collect interest on unpaid
26civil money penalties.

 

 

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

 

 

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1    alternate payee shall be permanently prohibited from
2    participating as an owner, an officer, or an individual
3    with management responsibility with an alternate payee in
4    the Illinois Medical Assistance Program, if after
5    reasonable notice and opportunity for a hearing the
6    Illinois Department finds that:
7            (1) the alternate payee is not complying with the
8        Department's policy or rules and regulations, or with
9        the terms and conditions prescribed by the Illinois
10        Department in its alternate payee registration
11        agreement; or
12            (2) the alternate payee has failed to keep or make
13        available for inspection, audit, or copying, after
14        receiving a written request from the Illinois
15        Department, such records regarding payments claimed as
16        an alternate payee; or
17            (3) the alternate payee has failed to furnish any
18        information requested by the Illinois Department
19        regarding payments claimed as an alternate payee; or
20            (4) the alternate payee has knowingly made, or
21        caused to be made, any false statement or
22        representation of a material fact in connection with
23        the administration of the Illinois Medical Assistance
24        Program; or
25            (5) the alternate payee, a person with management
26        responsibility for an alternate payee, an officer or

 

 

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1        person owning, either directly or indirectly, 5% or
2        more of the shares of stock or other evidences of
3        ownership in a corporate alternate payee, or a partner
4        in a partnership which is an alternate payee:
5                (a) was previously terminated, suspended, or
6            excluded from participation as a vendor in the
7            Illinois Medical Assistance Program, or was
8            previously revoked as an alternate payee in the
9            Illinois Medical Assistance Program, or was
10            terminated, suspended, or excluded from
11            participation as a vendor in a medical assistance
12            program in another state that is of the same kind
13            as the program of medical assistance provided
14            under Article V of this Code; or
15                (b) was a person with management
16            responsibility for a vendor previously terminated,
17            suspended, or excluded from participation as a
18            vendor in the Illinois Medical Assistance Program,
19            or was previously revoked as an alternate payee in
20            the Illinois Medical Assistance Program, or was
21            terminated, suspended, or excluded from
22            participation as a vendor in a medical assistance
23            program in another state that is of the same kind
24            as the program of medical assistance provided
25            under Article V of this Code, during the time of
26            conduct which was the basis for that vendor's

 

 

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

 

 

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1            as the program of medical assistance provided
2            under Article V of this Code, during the time of
3            conduct which was the basis for that vendor's
4            termination, suspension, or exclusion or alternate
5            payee's revocation; or
6            (6) the alternate payee, a person with management
7        responsibility for an alternate payee, an officer or
8        person owning, either directly or indirectly, 5% or
9        more of the shares of stock or other evidences of
10        ownership in a corporate alternate payee, or a partner
11        in a partnership which is an alternate payee:
12                (a) has engaged in conduct prohibited by
13            applicable federal or State law or regulation
14            relating to the Illinois Medical Assistance
15            Program; or
16                (b) was a person with management
17            responsibility for a vendor or alternate payee at
18            the time that the vendor or alternate payee engaged
19            in practices prohibited by applicable federal or
20            State law or regulation relating to the Illinois
21            Medical Assistance Program; or
22                (c) was an officer, or person owning, either
23            directly or indirectly, 5% or more of the shares of
24            stock or other evidences of ownership in a vendor
25            or alternate payee at the time such vendor or
26            alternate payee engaged in practices prohibited by

 

 

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

 

 

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

 

 

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1        and cite the circumstances under which withholding
2        will be terminated.
3            (3) Specify, when appropriate, which type or types
4        of Medicaid claims withholding is effective.
5            (4) Inform the provider or alternate payee of the
6        right to submit written evidence for reconsideration
7        of the withholding by the Illinois Department.
8            (5) Inform the provider or alternate payee that a
9        written request may be made to the Illinois Department
10        for full or partial release of withheld payments and
11        that such requests may be made at any time after the
12        Department first withholds such payments.
13        (b) All withholding-of-payment actions under this
14    subsection shall be temporary and shall not continue after
15    any of the following:
16            (1) The Illinois Department or the prosecuting
17        authorities determine that there is insufficient
18        evidence of fraud or willful misrepresentation by the
19        provider or alternate payee.
20            (2) Legal proceedings related to the provider's or
21        alternate payee's alleged fraud, willful
22        misrepresentation, violations of this Act, or
23        violations of the Illinois Department's administrative
24        rules are completed.
25            (3) The withholding of payments for a period of 3
26        years.

 

 

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1        (c) The Illinois Department may adopt all rules
2    necessary to implement this subsection (K).
3    (K-5) The Illinois Department may withhold payments, in
4whole or in part, to a provider or alternate payee upon
5initiation of an audit, quality of care review, investigation
6when there is a credible allegation of fraud, or the provider
7or alternate payee demonstrating a clear failure to cooperate
8with the Illinois Department such that the circumstances give
9rise to the need for a withholding of payments. As used in this
10subsection, "credible allegation" is defined to include an
11allegation from any source, including, but not limited to,
12fraud hotline complaints, claims data mining, patterns
13identified through provider audits, civil actions filed under
14the Illinois False Claims Act, and law enforcement
15investigations. An allegation is considered to be credible when
16it has indicia of reliability. The Illinois Department may
17withhold payments without first notifying the provider or
18alternate payee of its intention to withhold such payments. A
19provider or alternate payee may request a hearing or a
20reconsideration of payment withholding, and the Illinois
21Department must grant such a request. The Illinois Department
22shall state by rule a process and criteria by which a provider
23or alternate payee may request a hearing or a reconsideration
24for the full or partial release of payments withheld under this
25subsection. This request may be made at any time after the
26Illinois Department first withholds such payments.

 

 

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

 

 

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1    subsection shall be temporary and shall not continue after
2    any of the following:
3            (1) The Illinois Department determines that there
4        is insufficient evidence of fraud, or the provider or
5        alternate payee demonstrates clear cooperation with
6        the Illinois Department, as determined by the Illinois
7        Department, such that the circumstances do not give
8        rise to the need for withholding of payments; or
9            (2) The withholding of payments has lasted for a
10        period in excess of 3 years.
11        (c) The Illinois Department may adopt all rules
12    necessary to implement this subsection (K-5).
13    (L) The Illinois Department shall establish a protocol to
14enable health care providers to disclose an actual or potential
15violation of this Section pursuant to a self-referral
16disclosure protocol, referred to in this subsection as "the
17protocol". The protocol shall include direction for health care
18providers on a specific person, official, or office to whom
19such disclosures shall be made. The Illinois Department shall
20post information on the protocol on the Illinois Department's
21public website. The Illinois Department may adopt rules
22necessary to implement this subsection (L). In addition to
23other factors that the Illinois Department finds appropriate,
24the Illinois Department may consider a health care provider's
25timely use or failure to use the protocol in considering the
26provider's failure to comply with this Code.

 

 

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1    (M) Notwithstanding any other provision of this Code, the
2Illinois Department, at its discretion, may exempt an entity
3licensed under the Nursing Home Care Act and the ID/DD
4Community Care Act from the provisions of subsections (A-15),
5(B), and (C) of this Section if the licensed entity is in
6receivership.
7(Source: P.A. 97-689, eff. 6-14-12; 97-1150, eff. 1-25-13.)
 
8    Section 99. Effective date. This Act takes effect upon
9becoming law.