Sen. Don Harmon

Filed: 5/20/2016

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 5539

2    AMENDMENT NO. ______. Amend House Bill 5539 by replacing
3everything after the enacting clause with the following:
 
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:

 

 

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1        (a) Such vendor is not complying with the Department's
2    policy or rules and regulations, or with the terms and
3    conditions prescribed by the Illinois Department in its
4    vendor agreement, which document shall be developed by the
5    Department as a result of negotiations with each vendor
6    category, including physicians, hospitals, long term care
7    facilities, pharmacists, optometrists, podiatric
8    physicians, and dentists setting forth the terms and
9    conditions applicable to the participation of each vendor
10    group in the program; or
11        (b) Such vendor has failed to keep or make available
12    for inspection, audit or copying, after receiving a written
13    request from the Illinois Department, such records
14    regarding payments claimed for providing services. This
15    section does not require vendors to make available patient
16    records of patients for whom services are not reimbursed
17    under this Code; or
18        (c) Such vendor has failed to furnish any information
19    requested by the Department regarding payments for
20    providing goods or services; or
21        (d) Such vendor has knowingly made, or caused to be
22    made, any false statement or representation of a material
23    fact in connection with the administration of the medical
24    assistance program; or
25        (e) Such vendor has furnished goods or services to a
26    recipient which are (1) in excess of need, (2) harmful, or

 

 

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

 

 

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

 

 

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1        applicable federal or State law or regulation; or
2            (2) was a person with management responsibility
3        for a vendor at the time that such vendor engaged in
4        practices prohibited by applicable federal or State
5        law or regulation; or
6            (3) was an officer, or person owning, either
7        directly or indirectly, 5% or more of the shares of
8        stock or other evidences of ownership in a vendor at
9        the time such vendor engaged in practices prohibited by
10        applicable federal or State law or regulation; or
11            (4) was an owner of a sole proprietorship or
12        partner of a partnership which was a vendor at the time
13        such vendor engaged in practices prohibited by
14        applicable federal or State law or regulation; or
15        (h) The direct or indirect ownership of the vendor
16    (including the ownership of a vendor that is a sole
17    proprietorship, a partner's interest in a vendor that is a
18    partnership, or ownership of 5% or more of the shares of
19    stock or other evidences of ownership in a corporate
20    vendor) has been transferred by an individual who is
21    terminated, suspended, or excluded or barred from
22    participating as a vendor to the individual's spouse,
23    child, brother, sister, parent, grandparent, grandchild,
24    uncle, aunt, niece, nephew, cousin, or relative by
25    marriage.
26    (A-5) The Illinois Department may deny, suspend, or

 

 

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

 

 

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

 

 

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1any person, firm, corporation, association, agency,
2institution, or other legal entity to participate as a vendor
3of goods or services to recipients under the medical assistance
4program under Article V if, after reasonable notice and
5opportunity for a hearing, the Illinois Department finds:
6        (1) The applicant or any person with management
7    responsibility for the applicant; an officer or member of
8    the board of directors of an applicant; an entity owning
9    (directly or indirectly) 5% or more of the shares of stock
10    or other evidences of ownership in a corporate vendor
11    applicant; an owner of a sole proprietorship applicant; a
12    partner in a partnership applicant; or a technical or other
13    advisor to an applicant has a debt owed to the Illinois
14    Department, and no payment arrangements acceptable to the
15    Illinois Department have been made by the applicant.
16        (2) The applicant or any person with management
17    responsibility for the applicant; an officer or member of
18    the board of directors of an applicant; an entity owning
19    (directly or indirectly) 5% or more of the shares of stock
20    or other evidences of ownership in a corporate vendor
21    applicant; an owner of a sole proprietorship applicant; a
22    partner in a partnership vendor applicant; or a technical
23    or other advisor to an applicant was (i) a person with
24    management responsibility, (ii) an officer or member of the
25    board of directors of an applicant, (iii) an entity owning
26    (directly or indirectly) 5% or more of the shares of stock

 

 

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1    or other evidences of ownership in a corporate vendor, (iv)
2    an owner of a sole proprietorship, (v) a partner in a
3    partnership vendor, (vi) a technical or other advisor to a
4    vendor, during a period of time where the conduct of that
5    vendor resulted in a debt owed to the Illinois Department,
6    and no payment arrangements acceptable to the Illinois
7    Department have been made by that vendor.
8        (3) There is a credible allegation of the use,
9    transfer, or lease of assets of any kind to an applicant
10    from a current or prior vendor who has a debt owed to the
11    Illinois Department, no payment arrangements acceptable to
12    the Illinois Department have been made by that vendor or
13    the vendor's alternate payee, and the applicant knows or
14    should have known of such debt.
15        (4) There is a credible allegation of a transfer of
16    management responsibilities, or direct or indirect
17    ownership, to an applicant from a current or prior vendor
18    who has a debt owed to the Illinois Department, and no
19    payment arrangements acceptable to the Illinois Department
20    have been made by that vendor or the vendor's alternate
21    payee, and the applicant knows or should have known of such
22    debt.
23        (5) There is a credible allegation of the use,
24    transfer, or lease of assets of any kind to an applicant
25    who is a spouse, child, brother, sister, parent,
26    grandparent, grandchild, uncle, aunt, niece, relative by

 

 

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1    marriage, nephew, cousin, or relative of a current or prior
2    vendor who has a debt owed to the Illinois Department and
3    no payment arrangements acceptable to the Illinois
4    Department have been made.
5        (6) There is a credible allegation that the applicant's
6    previous affiliations with a provider of medical services
7    that has an uncollected debt, a provider that has been or
8    is subject to a payment suspension under a federal health
9    care program, or a provider that has been previously
10    excluded from participation in the medical assistance
11    program, poses a risk of fraud, waste, or abuse to the
12    Illinois Department.
13    As used in this subsection, "credible allegation" is
14defined to include an allegation from any source, including,
15but not limited to, fraud hotline complaints, claims data
16mining, patterns identified through provider audits, civil
17actions filed under the Illinois False Claims Act, and law
18enforcement investigations. An allegation is considered to be
19credible when it has indicia of reliability.
20    (B) The Illinois Department shall deny, suspend or
21terminate the eligibility of any person, firm, corporation,
22association, agency, institution or other legal entity to
23participate as a vendor of goods or services to recipients
24under the medical assistance program under Article V, or may
25exclude any such person or entity from participation as such a
26vendor:

 

 

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1        (1) immediately, if such vendor is not properly
2    licensed, certified, or authorized;
3        (2) within 30 days of the date when such vendor's
4    professional license, certification or other authorization
5    has been refused renewal, restricted, revoked, suspended,
6    or otherwise terminated; or
7        (3) if such vendor has been convicted of a violation of
8    this Code, as provided in Article VIIIA.
9    (C) Upon termination, suspension, or exclusion of a vendor
10of goods or services from participation in the medical
11assistance program authorized by this Article, a person with
12management responsibility for such vendor during the time of
13any conduct which served as the basis for that vendor's
14termination, suspension, or exclusion is barred from
15participation in the medical assistance program.
16    Upon termination, suspension, or exclusion of a corporate
17vendor, the officers and persons owning, directly or
18indirectly, 5% or more of the shares of stock or other
19evidences of ownership in the vendor during the time of any
20conduct which served as the basis for that vendor's
21termination, suspension, or exclusion are barred from
22participation in the medical assistance program. A person who
23owns, directly or indirectly, 5% or more of the shares of stock
24or other evidences of ownership in a terminated, suspended, or
25excluded vendor may not transfer his or her ownership interest
26in that vendor to his or her spouse, child, brother, sister,

 

 

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1parent, grandparent, grandchild, uncle, aunt, niece, nephew,
2cousin, or relative by marriage.
3    Upon termination, suspension, or exclusion of a sole
4proprietorship or partnership, the owner or partners during the
5time of any conduct which served as the basis for that vendor's
6termination, suspension, or exclusion are barred from
7participation in the medical assistance program. The owner of a
8terminated, suspended, or excluded vendor that is a sole
9proprietorship, and a partner in a terminated, suspended, or
10excluded vendor that is a partnership, may not transfer his or
11her ownership or partnership interest in that vendor to his or
12her spouse, child, brother, sister, parent, grandparent,
13grandchild, uncle, aunt, niece, nephew, cousin, or relative by
14marriage.
15    A person who owns, directly or indirectly, 5% or more of
16the shares of stock or other evidences of ownership in a
17corporate or limited liability company vendor who owes a debt
18to the Department, if that vendor has not made payment
19arrangements acceptable to the Department, shall not transfer
20his or her ownership interest in that vendor, or vendor assets
21of any kind, to his or her spouse, child, brother, sister,
22parent, grandparent, grandchild, uncle, aunt, niece, nephew,
23cousin, or relative by marriage.
24    Rules adopted by the Illinois Department to implement these
25provisions shall specifically include a definition of the term
26"management responsibility" as used in this Section. Such

 

 

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1definition shall include, but not be limited to, typical job
2titles, and duties and descriptions which will be considered as
3within the definition of individuals with management
4responsibility for a provider.
5    A vendor or a prior vendor who has been terminated,
6excluded, or suspended from the medical assistance program, or
7from another state or federal medical assistance or health care
8program, and any individual currently or previously barred from
9the medical assistance program, or from another state or
10federal medical assistance or health care program, as a result
11of being an officer or a person owning, directly or indirectly,
125% or more of the shares of stock or other evidences of
13ownership in a corporate or limited liability company vendor
14during the time of any conduct which served as the basis for
15that vendor's termination, suspension, or exclusion, may be
16required to post a surety bond as part of a condition of
17enrollment or participation in the medical assistance program.
18The Illinois Department shall establish, by rule, the criteria
19and requirements for determining when a surety bond must be
20posted and the value of the bond.
21    A vendor or a prior vendor who has a debt owed to the
22Illinois Department and any individual currently or previously
23barred from the medical assistance program, or from another
24state or federal medical assistance or health care program, as
25a result of being an officer or a person owning, directly or
26indirectly, 5% or more of the shares of stock or other

 

 

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1evidences of ownership in that corporate or limited liability
2company vendor during the time of any conduct which served as
3the basis for the debt, may be required to post a surety bond
4as part of a condition of enrollment or participation in the
5medical assistance program. The Illinois Department shall
6establish, by rule, the criteria and requirements for
7determining when a surety bond must be posted and the value of
8the bond.
9    (D) If a vendor has been suspended from the medical
10assistance program under Article V of the Code, the Director
11may require that such vendor correct any deficiencies which
12served as the basis for the suspension. The Director shall
13specify in the suspension order a specific period of time,
14which shall not exceed one year from the date of the order,
15during which a suspended vendor shall not be eligible to
16participate. At the conclusion of the period of suspension the
17Director shall reinstate such vendor, unless he finds that such
18vendor has not corrected deficiencies upon which the suspension
19was based.
20    If a vendor has been terminated, suspended, or excluded
21from the medical assistance program under Article V, such
22vendor shall be barred from participation for at least one
23year, except that if a vendor has been terminated, suspended,
24or excluded based on a conviction of a violation of Article
25VIIIA or a conviction of a felony based on fraud or a willful
26misrepresentation related to (i) the medical assistance

 

 

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1program under Article V, (ii) a federal or another state's
2medical assistance or health care program, or (iii) the
3provision of health care services, then the vendor shall be
4barred from participation for 5 years or for the length of the
5vendor's sentence for that conviction, whichever is longer. At
6the end of one year a vendor who has been terminated,
7suspended, or excluded may apply for reinstatement to the
8program. Upon proper application to be reinstated such vendor
9may be deemed eligible by the Director providing that such
10vendor meets the requirements for eligibility under this Code.
11If such vendor is deemed not eligible for reinstatement, he
12shall be barred from again applying for reinstatement for one
13year from the date his application for reinstatement is denied.
14    A vendor whose termination, suspension, or exclusion from
15participation in the Illinois medical assistance program under
16Article V was based solely on an action by a governmental
17entity other than the Illinois Department may, upon
18reinstatement by that governmental entity or upon reversal of
19the termination, suspension, or exclusion, apply for
20rescission of the termination, suspension, or exclusion from
21participation in the Illinois medical assistance program. Upon
22proper application for rescission, the vendor may be deemed
23eligible by the Director if the vendor meets the requirements
24for eligibility under this Code.
25    If a vendor has been terminated, suspended, or excluded and
26reinstated to the medical assistance program under Article V

 

 

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1and the vendor is terminated, suspended, or excluded a second
2or subsequent time from the medical assistance program, the
3vendor shall be barred from participation for at least 2 years,
4except that if a vendor has been terminated, suspended, or
5excluded a second time based on a conviction of a violation of
6Article VIIIA or a conviction of a felony based on fraud or a
7willful misrepresentation related to (i) the medical
8assistance program under Article V, (ii) a federal or another
9state's medical assistance or health care program, or (iii) the
10provision of health care services, then the vendor shall be
11barred from participation for life. At the end of 2 years, a
12vendor who has been terminated, suspended, or excluded may
13apply for reinstatement to the program. Upon application to be
14reinstated, the vendor may be deemed eligible if the vendor
15meets the requirements for eligibility under this Code. If the
16vendor is deemed not eligible for reinstatement, the vendor
17shall be barred from again applying for reinstatement for 2
18years from the date the vendor's application for reinstatement
19is denied.
20    (E) The Illinois Department may recover money improperly or
21erroneously paid, or overpayments, either by setoff, crediting
22against future billings or by requiring direct repayment to the
23Illinois Department. The Illinois Department may suspend or
24deny payment, in whole or in part, if such payment would be
25improper or erroneous or would otherwise result in overpayment.
26        (1) Payments may be suspended, denied, or recovered

 

 

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1    from a vendor or alternate payee: (i) for services rendered
2    in violation of the Illinois Department's provider
3    notices, statutes, rules, and regulations; (ii) for
4    services rendered in violation of the terms and conditions
5    prescribed by the Illinois Department in its vendor
6    agreement; (iii) for any vendor who fails to grant the
7    Office of Inspector General timely access to full and
8    complete records, including, but not limited to, records
9    relating to recipients under the medical assistance
10    program for the most recent 6 years, in accordance with
11    Section 140.28 of Title 89 of the Illinois Administrative
12    Code, and other information for the purpose of audits,
13    investigations, or other program integrity functions,
14    after reasonable written request by the Inspector General;
15    this subsection (E) does not require vendors to make
16    available the medical records of patients for whom services
17    are not reimbursed under this Code or to provide access to
18    medical records more than 6 years old; (iv) when the vendor
19    has knowingly made, or caused to be made, any false
20    statement or representation of a material fact in
21    connection with the administration of the medical
22    assistance program; or (v) when the vendor previously
23    rendered services while terminated, suspended, or excluded
24    from participation in the medical assistance program or
25    while terminated or excluded from participation in another
26    state or federal medical assistance or health care program.

 

 

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1    Notwithstanding any other provision to the contrary, the
2    Department shall not seek recovery of overpayments,
3    adjustments, or other amounts due that are over 6 years old
4    unless such overpayments, adjustments, or other amounts
5    due were made pursuant to a vendor's criminal activity.
6        (2) Notwithstanding any other provision of law, if a
7    vendor has the same taxpayer identification number
8    (assigned under Section 6109 of the Internal Revenue Code
9    of 1986) as is assigned to a vendor with past-due financial
10    obligations to the Illinois Department, the Illinois
11    Department may make any necessary adjustments to payments
12    to that vendor in order to satisfy any past-due
13    obligations, regardless of whether the vendor is assigned a
14    different billing number under the medical assistance
15    program.
16    (E-5) Civil monetary penalties.
17        (1) As used in this subsection (E-5):
18            (a) "Knowingly" means that a person, with respect
19        to information: (i) has actual knowledge of the
20        information; (ii) acts in deliberate ignorance of the
21        truth or falsity of the information; or (iii) 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            (b) "Overpayment" means any funds that a person
26        receives or retains from the medical assistance

 

 

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

 

 

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

 

 

09900HB5539sam001- 21 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 22 -LRB099 19598 KTG 49013 a

1            participating in the medical assistance program or
2            a federal or state health care program, and who
3            knows or should know of the action constituting the
4            basis for the exclusion; or
5                (ii) is an officer or managing employee of such
6            an entity;
7            (e) offers or transfers remuneration to any
8        individual eligible for benefits under the medical
9        assistance program that such person knows or should
10        know is likely to influence such individual to order or
11        receive from a particular vendor, provider,
12        practitioner, or supplier any item or service for which
13        payment may be made, in whole or in part, under the
14        medical assistance program;
15            (f) arranges or contracts (by employment or
16        otherwise) with an individual or entity that the person
17        knows or should know is excluded from participation in
18        the medical assistance program or a federal or state
19        health care program, for the provision of items or
20        services for which payment may be made under such a
21        program;
22            (g) commits an act described in subsection (b) or
23        (c) of Section 8A-3;
24            (h) knowingly makes, uses, or causes to be made or
25        used, a false record or statement material to a false
26        or fraudulent claim for payment for items and services

 

 

09900HB5539sam001- 23 -LRB099 19598 KTG 49013 a

1        furnished under the medical assistance program;
2            (i) fails to grant timely access, upon reasonable
3        request (as defined by the Department by rule), to the
4        Inspector General, for the purpose of audits,
5        investigations, evaluations, or other statutory
6        functions of the Inspector General of the Department;
7            (j) orders or prescribes a medical or other item or
8        service during a period in which the person was
9        excluded from the medical assistance program or a
10        federal or state health care program, in the case where
11        the person knows or should know that a claim for such
12        medical or other item or service will be made under
13        such a program;
14            (k) knowingly makes or causes to be made any false
15        statement, omission, or misrepresentation of a
16        material fact in any application, bid, or contract to
17        participate or enroll as a vendor or provider of
18        services or a supplier under the medical assistance
19        program;
20            (l) knows of an overpayment and does not report and
21        return the overpayment to the Department in accordance
22        with paragraph (6);
23    shall be subject, in addition to any other penalties that
24    may be prescribed by law, to a civil money penalty of not
25    more than $10,000 for each item or service (or, in cases
26    under subparagraph (c), $15,000 for each individual with

 

 

09900HB5539sam001- 24 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 25 -LRB099 19598 KTG 49013 a

1    the medical assistance program.
2        (4) The Illinois Department may seek the civil monetary
3    penalties and exclusion, termination, suspension, or
4    barment identified in this subsection (E-5). Prior to the
5    imposition of any penalties or sanctions, the affected
6    person shall be afforded an opportunity for a hearing after
7    reasonable notice. The Department shall establish hearing
8    procedures by rule.
9        (5) Any final order, decision, or other determination
10    made, issued, or executed by the Director under the
11    provisions of this subsection (E-5), whereby a person is
12    aggrieved, shall be subject to review in accordance with
13    the provisions of the Administrative Review Law, and the
14    rules adopted pursuant thereto, which shall apply to and
15    govern all proceedings for the judicial review of final
16    administrative decisions of the Director.
17        (6)(a) If a person has received an overpayment, the
18    person shall:
19            (i) report and return the overpayment to the
20        Department at the correct address; and
21            (ii) notify the Department in writing of the reason
22        for the overpayment.
23        (b) An overpayment must be reported and returned under
24    subparagraph (a) by the later of:
25            (i) the date which is 60 days after the date on
26        which the overpayment was identified; or

 

 

09900HB5539sam001- 26 -LRB099 19598 KTG 49013 a

1            (ii) the date any corresponding cost report is due,
2        if applicable.
3    (E-10) A vendor who disputes an overpayment identified as
4part of a Department audit shall utilize the Department's
5self-referral disclosure protocol as set forth under this Code
6to identify, investigate, and return to the Department any
7undisputed audit overpayment amount. Unless the disputed
8overpayment amount is subject to a fraud payment suspension, or
9involves a termination sanction, the Department shall defer the
10recovery of the disputed overpayment amount up to one year
11after the date of the Department's final audit determination,
12or earlier, or as required by State or federal law. If the
13administrative hearing extends beyond one year, and such delay
14was not caused by the request of the vendor, then the
15Department shall not recover the disputed overpayment amount
16until the date of the final administrative decision. If a final
17administrative decision establishes that the disputed
18overpayment amount is owed to the Department, then the amount
19shall be immediately due to the Department. The Department
20shall be entitled to recover interest from the vendor on the
21overpayment amount from the date of the overpayment through the
22date the vendor returns the overpayment to the Department at a
23rate not to exceed the Wall Street Journal Prime Rate, as
24published from time to time, but not to exceed 5%. Any interest
25billed by the Department shall be due immediately upon receipt
26of the Department's billing statement.

 

 

09900HB5539sam001- 27 -LRB099 19598 KTG 49013 a

1    (F) The Illinois Department may withhold payments to any
2vendor or alternate payee prior to or during the pendency of
3any audit or proceeding under this Section, and through the
4pendency of any administrative appeal or administrative review
5by any court proceeding. The Illinois Department shall state by
6rule with as much specificity as practicable the conditions
7under which payments will not be withheld under this Section.
8Payments may be denied for bills submitted with service dates
9occurring during the pendency of a proceeding, after a final
10decision has been rendered, or after the conclusion of any
11administrative appeal, where the final administrative decision
12is to terminate, exclude, or suspend eligibility to participate
13in the medical assistance program. The Illinois Department
14shall state by rule with as much specificity as practicable the
15conditions under which payments will not be denied for such
16bills. The Illinois Department shall state by rule a process
17and criteria by which a vendor or alternate payee may request
18full or partial release of payments withheld under this
19subsection. The Department must complete a proceeding under
20this Section in a timely manner.
21    Notwithstanding recovery allowed under subsection (E) or
22this subsection (F), the Illinois Department may withhold
23payments to any vendor or alternate payee who is not properly
24licensed, certified, or in compliance with State or federal
25agency regulations. Payments may be denied for bills submitted
26with service dates occurring during the period of time that a

 

 

09900HB5539sam001- 28 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 29 -LRB099 19598 KTG 49013 a

1    If the Illinois Department withholds payments to a vendor
2or alternate payee under this subsection, the Department shall
3not release those payments to the vendor or alternate payee
4while any criminal proceeding related to the indictment or
5charge is pending unless the Department determines that there
6is good cause to release the payments before completion of the
7proceeding. If the indictment or charge results in the
8individual's conviction, the Illinois Department shall retain
9all withheld payments, which shall be considered forfeited to
10the Department. If the indictment or charge does not result in
11the individual's conviction, the Illinois Department shall
12release to the vendor or alternate payee all withheld payments.
13    (F-10) If the Illinois Department establishes that the
14vendor or alternate payee owes a debt to the Illinois
15Department, and the vendor or alternate payee subsequently
16fails to pay or make satisfactory payment arrangements with the
17Illinois Department for the debt owed, the Illinois Department
18may seek all remedies available under the law of this State to
19recover the debt, including, but not limited to, wage
20garnishment or the filing of claims or liens against the vendor
21or alternate payee.
22    (F-15) Enforcement of judgment.
23        (1) Any fine, recovery amount, other sanction, or costs
24    imposed, or part of any fine, recovery amount, other
25    sanction, or cost imposed, remaining unpaid after the
26    exhaustion of or the failure to exhaust judicial review

 

 

09900HB5539sam001- 30 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 31 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 32 -LRB099 19598 KTG 49013 a

1or hereafter amended, and the rules adopted pursuant thereto,
2shall apply to and govern all proceedings for the judicial
3review of final administrative decisions of the Illinois
4Department under this Section. The term "administrative
5decision" is defined as in Section 3-101 of the Code of Civil
6Procedure.
7    (G-5) Vendors who pose a risk of fraud, waste, abuse, or
8harm.
9        (1) Notwithstanding any other provision in this
10    Section, the Department may terminate, suspend, or exclude
11    vendors who pose a risk of fraud, waste, abuse, or harm
12    from participation in the medical assistance program prior
13    to an evidentiary hearing but after reasonable notice and
14    opportunity to respond as established by the Department by
15    rule.
16        (2) Vendors who pose a risk of fraud, waste, abuse, or
17    harm shall submit to a fingerprint-based criminal
18    background check on current and future information
19    available in the State system and current information
20    available through the Federal Bureau of Investigation's
21    system by submitting all necessary fees and information in
22    the form and manner prescribed by the Department of State
23    Police. The following individuals shall be subject to the
24    check:
25            (A) In the case of a vendor that is a corporation,
26        every shareholder who owns, directly or indirectly, 5%

 

 

09900HB5539sam001- 33 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 34 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 35 -LRB099 19598 KTG 49013 a

1        liability.
2            (D) "Harm" means physical, mental, or monetary
3        damage to recipients or to the medical assistance
4        program.
5    (G-6) The Illinois Department, upon making a determination
6based upon information in the possession of the Illinois
7Department that continuation of participation in the medical
8assistance program by a vendor would constitute an immediate
9danger to the public, may immediately suspend such vendor's
10participation in the medical assistance program without a
11hearing. In instances in which the Illinois Department
12immediately suspends the medical assistance program
13participation of a vendor under this Section, a hearing upon
14the vendor's participation must be convened by the Illinois
15Department within 15 days after such suspension and completed
16without appreciable delay. Such hearing shall be held to
17determine whether to recommend to the Director that the
18vendor's medical assistance program participation be denied,
19terminated, suspended, placed on provisional status, or
20reinstated. In the hearing, any evidence relevant to the vendor
21constituting an immediate danger to the public may be
22introduced against such vendor; provided, however, that the
23vendor, or his or her counsel, shall have the opportunity to
24discredit, impeach, and submit evidence rebutting such
25evidence.
26    (H) Nothing contained in this Code shall in any way limit

 

 

09900HB5539sam001- 36 -LRB099 19598 KTG 49013 a

1or otherwise impair the authority or power of any State agency
2responsible for licensing of vendors.
3    (I) Based on a finding of noncompliance on the part of a
4nursing home with any requirement for certification under Title
5XVIII or XIX of the Social Security Act (42 U.S.C. Sec. 1395 et
6seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois Department
7may impose one or more of the following remedies after notice
8to the facility:
9        (1) Termination of the provider agreement.
10        (2) Temporary management.
11        (3) Denial of payment for new admissions.
12        (4) Civil money penalties.
13        (5) Closure of the facility in emergency situations or
14    transfer of residents, or both.
15        (6) State monitoring.
16        (7) Denial of all payments when the U.S. Department of
17    Health and Human Services has imposed this sanction.
18    The Illinois Department shall by rule establish criteria
19governing continued payments to a nursing facility subsequent
20to termination of the facility's provider agreement if, in the
21sole discretion of the Illinois Department, circumstances
22affecting the health, safety, and welfare of the facility's
23residents require those continued payments. The Illinois
24Department may condition those continued payments on the
25appointment of temporary management, sale of the facility to
26new owners or operators, or other arrangements that the

 

 

09900HB5539sam001- 37 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 38 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 39 -LRB099 19598 KTG 49013 a

1        agreement; or
2            (2) the alternate payee has failed to keep or make
3        available for inspection, audit, or copying, after
4        receiving a written request from the Illinois
5        Department, such records regarding payments claimed as
6        an alternate payee; or
7            (3) the alternate payee has failed to furnish any
8        information requested by the Illinois Department
9        regarding payments claimed as an alternate payee; or
10            (4) the alternate payee has knowingly made, or
11        caused to be made, any false statement or
12        representation of a material fact in connection with
13        the administration of the Illinois Medical Assistance
14        Program; or
15            (5) the alternate payee, a person with management
16        responsibility for an alternate payee, an officer or
17        person owning, either directly or indirectly, 5% or
18        more of the shares of stock or other evidences of
19        ownership in a corporate alternate payee, or a partner
20        in a partnership which is an alternate payee:
21                (a) was previously terminated, suspended, or
22            excluded from participation as a vendor in the
23            Illinois Medical Assistance Program, or was
24            previously revoked as an alternate payee in the
25            Illinois Medical Assistance Program, or was
26            terminated, suspended, or excluded from

 

 

09900HB5539sam001- 40 -LRB099 19598 KTG 49013 a

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

 

 

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

 

 

09900HB5539sam001- 42 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 43 -LRB099 19598 KTG 49013 a

1            (7) the direct or indirect ownership of the vendor
2        or alternate payee (including the ownership of a vendor
3        or alternate payee that is a partner's interest in a
4        vendor or alternate payee, or ownership of 5% or more
5        of the shares of stock or other evidences of ownership
6        in a corporate vendor or alternate payee) has been
7        transferred by an individual who is terminated,
8        suspended, or excluded or barred from participating as
9        a vendor or is prohibited or revoked as an alternate
10        payee to the individual's spouse, child, brother,
11        sister, parent, grandparent, grandchild, uncle, aunt,
12        niece, nephew, cousin, or relative by marriage.
13    (K) The Illinois Department of Healthcare and Family
14Services may withhold payments, in whole or in part, to a
15provider or alternate payee where there is credible evidence,
16received from State or federal law enforcement or federal
17oversight agencies or from the results of a preliminary
18Department audit, that the circumstances giving rise to the
19need for a withholding of payments may involve fraud or willful
20misrepresentation under the Illinois Medical Assistance
21program. The Department shall by rule define what constitutes
22"credible" evidence for purposes of this subsection. The
23Department may withhold payments without first notifying the
24provider or alternate payee of its intention to withhold such
25payments. A provider or alternate payee may request a
26reconsideration of payment withholding, and the Department

 

 

09900HB5539sam001- 44 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 45 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 46 -LRB099 19598 KTG 49013 a

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

 

 

09900HB5539sam001- 47 -LRB099 19598 KTG 49013 a

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

 

 

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1        (c) The Illinois Department may adopt all rules
2    necessary to implement this subsection (K-5).
3    (L) The Illinois Department shall establish a protocol to
4enable health care providers to disclose an actual or potential
5violation of this Section pursuant to a self-referral
6disclosure protocol, referred to in this subsection as "the
7protocol". The protocol shall include direction for health care
8providers on a specific person, official, or office to whom
9such disclosures shall be made. The Illinois Department shall
10post information on the protocol on the Illinois Department's
11public website. The Illinois Department may adopt rules
12necessary to implement this subsection (L). In addition to
13other factors that the Illinois Department finds appropriate,
14the Illinois Department may consider a health care provider's
15timely use or failure to use the protocol in considering the
16provider's failure to comply with this Code.
17    (M) Notwithstanding any other provision of this Code, the
18Illinois Department, at its discretion, may exempt an entity
19licensed under the Nursing Home Care Act, the ID/DD Community
20Care Act, or the MC/DD Act from the provisions of subsections
21(A-15), (B), and (C) of this Section if the licensed entity is
22in receivership.
23(Source: P.A. 98-214, eff. 8-9-13; 98-550, eff. 8-27-13;
2498-756, eff. 7-16-14; 99-180, eff. 7-29-15.)
 
25    Section 99. Effective date. This Act takes effect upon

 

 

09900HB5539sam001- 49 -LRB099 19598 KTG 49013 a

1becoming law.".