Full Text of SB1330 98th General Assembly
SB1330 98TH GENERAL ASSEMBLY |
| | 98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014 SB1330 Introduced 2/5/2013, by Sen. Kwame Raoul SYNOPSIS AS INTRODUCED: |
| 305 ILCS 5/12-4.25 | from Ch. 23, par. 12-4.25 |
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Amends the Administration Article of the Illinois Public Aid Code. Establishes civil penalties ranging from $10,000 to $50,000 for any person (including a vendor, organization, agency, or other entity, but excluding a recipient) who: knowingly presents or causes to be presented a fraudulent claim for payment under the State's medical assistance program; knowingly gives or causes to be given to any person, with respect to coverage for inpatient hospital services under the medical assistance program, information that he or she knows or should know is false or misleading; arranges or contracts (by employment or otherwise) with an individual or entity that the person knows or should know is excluded from participation in a federal or state health care program, including, but not limited to, the medical assistance program, for the provision of items or services for which payment may be made under such a program; or commits other specified fraudulent acts. Provides that the Director of Healthcare and Family Services may make a determination to terminate, suspend, bar, or exclude the person from participation in the medical assistance program, but not before granting the affected individual, entity, or vendor an opportunity for a hearing after reasonable notice. Provides that a final order, decision, or other determination made by the Director is subject to review in accordance with the Administrative Review Law. Removes language allowing the Department to recover interest on the amount of an overpayment. Makes other changes. Effective immediately.
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| | | FISCAL NOTE ACT MAY APPLY | |
| | A BILL FOR |
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| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Public Aid Code is amended by | 5 | | changing 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 | 8 | | participation.
| 9 | | (A) The Illinois Department may deny, suspend, or
terminate | 10 | | the eligibility of any person, firm, corporation, association,
| 11 | | agency, institution or other legal entity to participate as a | 12 | | vendor of
goods or services to recipients under the medical | 13 | | assistance program
under Article V, or may exclude any such
| 14 | | person or entity from participation as such a vendor, and may
| 15 | | deny, suspend, or recover payments, if after reasonable notice | 16 | | and 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 | 20 | | terminate the
eligibility
of any person, firm, corporation, | 21 | | association, agency, institution, or other
legal entity to | 22 | | participate as a vendor of goods or services to recipients
| 23 | | under the medical assistance program under Article V, or may
| 24 | | exclude any such person or entity from participation as such a
| 25 | | vendor, if, after reasonable
notice and opportunity for a | 26 | | hearing, the Illinois Department finds that the
vendor; a |
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| 1 | | person with management responsibility for a vendor; an officer | 2 | | or
person owning, either directly or indirectly, 5% or more of | 3 | | the shares of stock
or other evidences of ownership in a | 4 | | corporate vendor; an owner of a sole
proprietorship that is a | 5 | | vendor; or a partner in a partnership that is a vendor
has been | 6 | | convicted of an offense based on fraud or willful
| 7 | | misrepresentation 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 | 19 | | terminate the eligibility of any person, firm, corporation, | 20 | | association, agency, institution, or other legal entity to | 21 | | participate as a vendor of goods or services to recipients | 22 | | under the medical assistance program under Article V, or may
| 23 | | exclude any such person or entity from participation as such a
| 24 | | vendor, if, after reasonable notice and opportunity for a | 25 | | hearing, 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 | 2 | | indirectly, 5% or more of the shares of stock or other | 3 | | evidences of ownership in a corporate vendor, (iv) an owner of | 4 | | a sole proprietorship that is a vendor, or (v) a partner in a | 5 | | partnership that is a vendor has been convicted of an offense | 6 | | related to any of the following:
| 7 | | (1) Murder.
| 8 | | (2) A Class X felony under the Criminal Code of 1961.
| 9 | | (3) Sexual misconduct that may subject recipients to an | 10 | | undue risk of harm. | 11 | | (4) A criminal offense that may subject recipients to | 12 | | an undue risk of harm. | 13 | | (5) A crime of fraud or dishonesty. | 14 | | (6) A crime involving a controlled substance. | 15 | | (7) A misdemeanor relating to fraud, theft, | 16 | | embezzlement, breach of fiduciary responsibility, or other | 17 | | financial misconduct related to a health care program. | 18 | | (A-15) The Illinois Department may deny the eligibility of | 19 | | any person, firm, corporation, association, agency, | 20 | | institution, or other legal entity to participate as a vendor | 21 | | of goods or services to recipients under the medical assistance | 22 | | program under Article V if, after reasonable notice and | 23 | | opportunity for a hearing, the Illinois Department finds: | 24 | | (1) The applicant or any person with management | 25 | | responsibility for the applicant; an officer or member of | 26 | | the board of directors of an applicant; an entity owning |
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| 1 | | (directly or indirectly) 5% or more of the shares of stock | 2 | | or other evidences of ownership in a corporate vendor | 3 | | applicant; an owner of a sole proprietorship applicant; a | 4 | | partner in a partnership applicant; or a technical or other | 5 | | advisor to an applicant has a debt owed to the Illinois | 6 | | Department, and no payment arrangements acceptable to the | 7 | | Illinois Department have been made by the applicant. | 8 | | (2) The applicant or any person with management | 9 | | responsibility for the applicant; an officer or member of | 10 | | the board of directors of an applicant; an entity owning | 11 | | (directly or indirectly) 5% or more of the shares of stock | 12 | | or other evidences of ownership in a corporate vendor | 13 | | applicant; an owner of a sole proprietorship applicant; a | 14 | | partner in a partnership vendor applicant; or a technical | 15 | | or other advisor to an applicant was (i) a person with | 16 | | management responsibility, (ii) an officer or member of the | 17 | | board of directors of an applicant, (iii) an entity owning | 18 | | (directly or indirectly) 5% or more of the shares of stock | 19 | | or other evidences of ownership in a corporate vendor, (iv) | 20 | | an owner of a sole proprietorship, (v) a partner in a | 21 | | partnership vendor, (vi) a technical or other advisor to a | 22 | | vendor, during a period of time where the conduct of that | 23 | | vendor resulted in a debt owed to the Illinois Department, | 24 | | and no payment arrangements acceptable to the Illinois | 25 | | Department have been made by that vendor. | 26 | | (3) There is a credible allegation of the use, |
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| 1 | | transfer, or lease of assets of any kind to an applicant | 2 | | from a current or prior vendor who has a debt owed to the | 3 | | Illinois Department, no payment arrangements acceptable to | 4 | | the Illinois Department have been made by that vendor or | 5 | | the vendor's alternate payee, and the applicant knows or | 6 | | should have known of such debt. | 7 | | (4) There is a credible allegation of a transfer of | 8 | | management responsibilities, or direct or indirect | 9 | | ownership, to an applicant from a current or prior vendor | 10 | | who has a debt owed to the Illinois Department, and no | 11 | | payment arrangements acceptable to the Illinois Department | 12 | | have been made by that vendor or the vendor's alternate | 13 | | payee, and the applicant knows or should have known of such | 14 | | debt. | 15 | | (5) There is a credible allegation of the use, | 16 | | transfer, or lease of assets of any kind to an applicant | 17 | | who is a spouse, child, brother, sister, parent, | 18 | | grandparent, grandchild, uncle, aunt, niece, relative by | 19 | | marriage, nephew, cousin, or relative of a current or prior | 20 | | vendor who has a debt owed to the Illinois Department and | 21 | | no payment arrangements acceptable to the Illinois | 22 | | Department have been made. | 23 | | (6) There is a credible allegation that the applicant's | 24 | | previous affiliations with a provider of medical services | 25 | | that has an uncollected debt, a provider that has been or | 26 | | is subject to a payment suspension under a federal health |
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| 1 | | care program, or a provider that has been previously | 2 | | excluded from participation in the medical assistance | 3 | | program, poses a risk of fraud, waste, or abuse to the | 4 | | Illinois Department. | 5 | | As used in this subsection, "credible allegation" is | 6 | | defined to include an allegation from any source, including, | 7 | | but not limited to, fraud hotline complaints, claims data | 8 | | mining, patterns identified through provider audits, civil | 9 | | actions filed under the Illinois False Claims Act, and law | 10 | | enforcement investigations. An allegation is considered to be | 11 | | credible when it has indicia of reliability. | 12 | | (B) The Illinois Department shall deny, suspend or | 13 | | terminate the
eligibility of any person, firm, corporation, | 14 | | association, agency,
institution or other legal entity to | 15 | | participate as a vendor of goods or
services to recipients | 16 | | under the medical assistance program under
Article V, or may
| 17 | | exclude any such person or entity from participation as such a
| 18 | | vendor:
| 19 | | (1) immediately, if such vendor is not properly | 20 | | licensed, certified, or authorized;
| 21 | | (2) within 30 days of the date when such vendor's | 22 | | professional
license, certification or other authorization | 23 | | has been refused renewal, restricted,
revoked, suspended, | 24 | | or otherwise terminated; or
| 25 | | (3) if such vendor has been convicted of a violation of | 26 | | this Code, as
provided in Article VIIIA.
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| 1 | | (C) Upon termination, suspension, or exclusion of a vendor | 2 | | of goods or services from
participation in the medical | 3 | | assistance program authorized by this
Article, a person with | 4 | | management responsibility for such vendor during
the time of | 5 | | any conduct which served as the basis for that vendor's
| 6 | | termination, suspension, or exclusion is barred from | 7 | | participation in the medical assistance
program.
| 8 | | Upon termination, suspension, or exclusion of a corporate | 9 | | vendor, the officers and persons
owning, directly or | 10 | | indirectly, 5% or more of the shares of stock or
other | 11 | | evidences of ownership in the vendor during the time of any
| 12 | | conduct which served as the basis for that vendor's | 13 | | termination, suspension, or exclusion are
barred from | 14 | | participation in the medical assistance program. A person who
| 15 | | owns, directly or indirectly, 5% or more of the shares of stock | 16 | | or other
evidences of ownership in a terminated, suspended, or | 17 | | excluded vendor may not transfer his or
her ownership interest | 18 | | in that vendor to his or her spouse, child, brother,
sister, | 19 | | parent, grandparent, grandchild, uncle, aunt, niece, nephew, | 20 | | cousin, or
relative by marriage.
| 21 | | Upon termination, suspension, or exclusion of a sole | 22 | | proprietorship or partnership, the owner
or partners during the | 23 | | time of any conduct which served as the basis for
that vendor's | 24 | | termination, suspension, or exclusion are barred from | 25 | | participation in the medical
assistance program. The owner of a | 26 | | terminated, suspended, or excluded vendor that is a sole
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| 1 | | proprietorship, and a partner in a terminated, suspended, or | 2 | | excluded vendor that is a partnership, may
not transfer his or | 3 | | her ownership or partnership interest in that vendor to his
or | 4 | | her spouse, child, brother, sister, parent, grandparent, | 5 | | grandchild, uncle,
aunt, niece, nephew, cousin, or relative by | 6 | | marriage.
| 7 | | A person who owns, directly or indirectly, 5% or more of | 8 | | the shares of stock or other evidences of ownership in a | 9 | | corporate or limited liability company vendor who owes a debt | 10 | | to the Department, if that vendor has not made payment | 11 | | arrangements acceptable to the Department, shall not transfer | 12 | | his or her ownership interest in that vendor, or vendor assets | 13 | | of any kind, to his or her spouse, child, brother, sister, | 14 | | parent, grandparent, grandchild, uncle, aunt, niece, nephew, | 15 | | cousin, or relative by marriage. | 16 | | Rules adopted by the Illinois Department to implement these
| 17 | | provisions shall specifically include a definition of the term
| 18 | | "management responsibility" as used in this Section. Such | 19 | | definition
shall include, but not be limited to, typical job | 20 | | titles, and duties and
descriptions which will be considered as | 21 | | within the definition of
individuals with management | 22 | | responsibility for a provider.
| 23 | | A vendor or a prior vendor who has been terminated, | 24 | | excluded, or suspended from the medical assistance program, or | 25 | | from another state or federal medical assistance or health care | 26 | | program, and any individual currently or previously barred from |
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| 1 | | the medical assistance program, or from another state or | 2 | | federal medical assistance or health care program, as a result | 3 | | of being an officer or a person owning, directly or indirectly, | 4 | | 5% or more of the shares of stock or other evidences of | 5 | | ownership in a corporate or limited liability company vendor | 6 | | during the time of any conduct which served as the basis for | 7 | | that vendor's termination, suspension, or exclusion, may be | 8 | | required to post a surety bond as part of a condition of | 9 | | enrollment or participation in the medical assistance program. | 10 | | The Illinois Department shall establish, by rule, the criteria | 11 | | and requirements for determining when a surety bond must be | 12 | | posted and the value of the bond. | 13 | | A vendor or a prior vendor who has a debt owed to the | 14 | | Illinois Department and any individual currently or previously | 15 | | barred from the medical assistance program, or from another | 16 | | state or federal medical assistance or health care program, as | 17 | | a result of being an officer or a person owning, directly or | 18 | | indirectly, 5% or more of the shares of stock or other | 19 | | evidences of ownership in that corporate or limited liability | 20 | | company vendor during the time of any conduct which served as | 21 | | the basis for the debt, may be required to post a surety bond | 22 | | as part of a condition of enrollment or participation in the | 23 | | medical assistance program. The Illinois Department shall | 24 | | establish, by rule, the criteria and requirements for | 25 | | determining when a surety bond must be posted and the value of | 26 | | the bond. |
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| 1 | | (D) If a vendor has been suspended from the medical | 2 | | assistance
program under Article V of the Code, the Director | 3 | | may require that such
vendor correct any deficiencies which | 4 | | served as the basis for the
suspension. The Director shall | 5 | | specify in the suspension order a specific
period of time, | 6 | | which shall not exceed one year from the date of the
order, | 7 | | during which a suspended vendor shall not be eligible to
| 8 | | participate. At the conclusion of the period of suspension the | 9 | | Director
shall reinstate such vendor, unless he finds that such | 10 | | vendor has not
corrected deficiencies upon which the suspension | 11 | | was based.
| 12 | | If a vendor has been terminated, suspended, or excluded | 13 | | from the medical assistance program
under Article V, such | 14 | | vendor shall be barred from participation for at
least one | 15 | | year, except that if a vendor has been terminated, suspended, | 16 | | or excluded based on a
conviction of a
violation of Article | 17 | | VIIIA or a conviction of a felony based on fraud or a
willful | 18 | | misrepresentation related to (i) the medical assistance | 19 | | program under
Article V, (ii) a federal or another state's | 20 | | medical assistance or health care program, or (iii) the | 21 | | provision of health care services, then
the vendor shall be | 22 | | barred from participation for 5 years or for the length of
the | 23 | | vendor's sentence for that conviction, whichever is longer. At | 24 | | the end of
one year a vendor who has been terminated, | 25 | | suspended, or excluded
may apply for reinstatement to the | 26 | | program. Upon proper application to
be reinstated such vendor |
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| 1 | | may be deemed eligible by the Director
providing that such | 2 | | vendor meets the requirements for eligibility under
this Code. | 3 | | If such vendor is deemed not eligible for
reinstatement, he
| 4 | | shall be barred from again applying for reinstatement for one | 5 | | year from the
date his application for reinstatement is denied.
| 6 | | A vendor whose termination, suspension, or exclusion from | 7 | | participation in the Illinois medical
assistance program under | 8 | | Article V was based solely on an action by a
governmental | 9 | | entity other than the Illinois Department may, upon | 10 | | reinstatement
by that governmental entity or upon reversal of | 11 | | the termination, suspension, or exclusion, apply for
| 12 | | rescission of the termination, suspension, or exclusion from | 13 | | participation in the Illinois medical
assistance program. Upon | 14 | | proper application for rescission, the vendor may be
deemed | 15 | | eligible by the Director if the vendor meets the requirements | 16 | | for
eligibility under this Code.
| 17 | | If a vendor has been terminated, suspended, or excluded and | 18 | | reinstated to the medical assistance
program under Article V | 19 | | and the vendor is terminated, suspended, or excluded a second | 20 | | or subsequent
time from the medical assistance program, the | 21 | | vendor shall be barred from
participation for at least 2 years, | 22 | | except that if a vendor has been
terminated, suspended, or | 23 | | excluded a second time based on a
conviction of a violation of | 24 | | Article VIIIA or a conviction of a felony based on
fraud or a | 25 | | willful misrepresentation related to (i) the medical | 26 | | assistance
program under Article V, (ii) a federal or another |
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| 1 | | state's medical assistance or health care program, or (iii) the | 2 | | provision of health care
services, then the vendor shall be | 3 | | barred from participation for life. At
the end of 2 years, a | 4 | | vendor who has
been terminated, suspended, or excluded may | 5 | | apply for reinstatement to the program. Upon application
to be | 6 | | reinstated, the vendor may be deemed eligible if the vendor | 7 | | meets the
requirements for eligibility under this Code. If the | 8 | | vendor is deemed not
eligible for reinstatement, the vendor | 9 | | shall be barred from again applying for
reinstatement for 2 | 10 | | years from the date the vendor's application for
reinstatement | 11 | | is denied.
| 12 | | (E) The Illinois Department may recover money improperly or
| 13 | | erroneously paid, or overpayments, either by setoff, crediting | 14 | | against
future billings or by requiring direct repayment to the | 15 | | Illinois
Department. The Illinois Department may suspend or | 16 | | deny payment, in whole or in part, if such payment would be | 17 | | improper or erroneous or would otherwise result in overpayment. | 18 | | (1) Payments may be suspended, denied, or recovered | 19 | | from a vendor or alternate payee: (i) for services rendered | 20 | | in violation of the Illinois Department's provider | 21 | | notices, statutes, rules, and regulations; (ii) for | 22 | | services rendered in violation of the terms and conditions | 23 | | prescribed by the Illinois Department in its vendor | 24 | | agreement; (iii) for any vendor who fails to grant the | 25 | | Office of Inspector General timely access to full and | 26 | | complete records, including, but not limited to, records |
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| 1 | | relating to recipients under the medical assistance | 2 | | program for the most recent 6 years, in accordance with | 3 | | Section 140.28 of Title 89 of the Illinois Administrative | 4 | | Code, and other information for the purpose of audits, | 5 | | investigations, or other program integrity functions, | 6 | | after reasonable written request by the Inspector General; | 7 | | this subsection (E) does not require vendors to make | 8 | | available the medical records of patients for whom services | 9 | | are not reimbursed under this Code or to provide access to | 10 | | medical records more than 6 years old; (iv) when the vendor | 11 | | has knowingly made, or caused to be made, any false | 12 | | statement or representation of a material fact in | 13 | | connection with the administration of the medical | 14 | | assistance program; or (v) when the vendor previously | 15 | | rendered services while terminated, suspended, or excluded | 16 | | from participation in the medical assistance program or | 17 | | while terminated or excluded from participation in another | 18 | | state or federal medical assistance or health care program. | 19 | | (2) Notwithstanding any other provision of law, if a | 20 | | vendor has the same taxpayer identification number | 21 | | (assigned under Section 6109 of the Internal Revenue Code | 22 | | of 1986) as is assigned to a vendor with past-due financial | 23 | | obligations to the Illinois Department, the Illinois | 24 | | Department may make any necessary adjustments to payments | 25 | | to that vendor in order to satisfy any past-due | 26 | | obligations, regardless of whether the vendor is assigned a |
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| 1 | | different billing number under the medical assistance | 2 | | program.
| 3 | | If the Illinois Department establishes through an | 4 | | administrative
hearing that the overpayments resulted from the | 5 | | vendor
or alternate payee knowingly making, using, or causing | 6 | | to be made or used, a false record or statement to obtain | 7 | | payment or other benefit from the medical assistance program | 8 | | under Article V, the Department may
recover interest on the | 9 | | amount of the payment or other benefit at the rate of 5% per | 10 | | annum.
In addition to any other penalties that may be | 11 | | prescribed by law, such a vendor or alternate payee shall be | 12 | | subject to civil penalties consisting of an amount not to | 13 | | exceed 3 times the amount of payment or other benefit resulting | 14 | | from each such false record or statement, and the sum of $2,000 | 15 | | for each such false record or statement for payment or other | 16 | | benefit. For purposes of this paragraph,
"knowingly" means that | 17 | | a vendor or alternate payee with respect to information: (i) | 18 | | has
actual knowledge of the information, (ii) acts in | 19 | | deliberate ignorance of the truth or falsity of the | 20 | | information, or (iii) acts in reckless disregard of the truth | 21 | | or falsity of the information. No proof of specific intent to | 22 | | defraud is required.
| 23 | | (E-5) Civil monetary penalties. | 24 | | (1) For purposes of this Section, "knowingly" means | 25 | | that a vendor or alternate payee, with respect to | 26 | | information: (i) has actual knowledge of the information, |
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| 1 | | (ii) acts in deliberate ignorance of the truth or falsity | 2 | | of the information, or (iii) acts in reckless disregard of | 3 | | the truth or falsity of the information. No proof of | 4 | | specific intent to defraud is required. | 5 | | (2) Any person (including a vendor, provider, | 6 | | organization, agency, or other entity, or an alternate | 7 | | payee thereof, but excluding a recipient) who: | 8 | | (a) knowingly presents or causes to be presented to | 9 | | an officer, employee, or agent of the Department or the | 10 | | State, a claim that the Department determines: | 11 | | (i) is for a medical or other item or service | 12 | | that the person knows or should know was not | 13 | | provided as claimed, including any person who | 14 | | engaged in a pattern or practice of presenting or | 15 | | causing to be presented a claim for an item or | 16 | | service that is based on a billing procedure code | 17 | | that the person knows or should know will result in | 18 | | a greater payment to the person than the billing | 19 | | procedure code the person knows or should know is | 20 | | applicable to the item or service actually | 21 | | provided; | 22 | | (ii) is for a medical or other item or service | 23 | | and the person knows or should know that the claim | 24 | | is false or fraudulent; | 25 | | (iii) is presented for a vendor physician's | 26 | | service, or an item or service incident to a vendor |
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| 1 | | physician's service, by a person who knows or | 2 | | should know that the individual who furnished, or | 3 | | who supervised the furnishing of, the service: | 4 | | (AA) was not licensed as a physician; | 5 | | (BB) was licensed as a physician but such | 6 | | license had been obtained through a | 7 | | misrepresentation of material fact (including | 8 | | cheating on an examination required for | 9 | | licensing); or | 10 | | (CC) represented to the patient at the | 11 | | time the service was furnished that the | 12 | | physician was certified in a medical specialty | 13 | | by the applicable specialty board, when the | 14 | | individual was not so certified; | 15 | | (iv) is for a medical or other item or service | 16 | | furnished during a period in which the person was | 17 | | excluded from the medical assistance program; or | 18 | | (v) is for a pattern of medical or other items | 19 | | or services that a person knows or should know are | 20 | | not medically necessary; | 21 | | (b) knowingly presents or causes to be presented to | 22 | | any person a request for payment which is in violation | 23 | | of the terms of an agreement with the Department or | 24 | | another requirement of the medical assistance program; | 25 | | (c) knowingly gives or causes to be given to any | 26 | | person, with respect to coverage for inpatient |
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| 1 | | hospital services under the medical assistance | 2 | | program, information that he or she knows or should | 3 | | know is false or misleading, and that could reasonably | 4 | | be expected to influence the decision when to discharge | 5 | | such person or other individual from the hospital; | 6 | | (d) in the case of a person who is not an | 7 | | organization, agency, or other entity, is excluded | 8 | | from participating in any federal or state health care | 9 | | program, including, but not limited to, the medical | 10 | | assistance program, and who, at the time of a violation | 11 | | of this subsection (E-5): | 12 | | (i) has a direct or indirect ownership or | 13 | | control interest in an entity that is | 14 | | participating in the medical assistance program, | 15 | | and who knows or should know of the action | 16 | | constituting the basis for the exclusion; or | 17 | | (ii) is an officer or managing employee of such | 18 | | an entity; | 19 | | (e) offers or transfers remuneration to any | 20 | | individual eligible for benefits under the medical | 21 | | assistance program that such person knows or should | 22 | | know is likely to influence such individual to order or | 23 | | receive from a particular provider, vendor, or | 24 | | supplier any item or service for which payment may be | 25 | | made, in whole or in part, under the medical assistance | 26 | | program; |
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| 1 | | (f) arranges or contracts (by employment or | 2 | | otherwise) with an individual or entity that the person | 3 | | knows or should know is excluded from participation in | 4 | | a federal or state health care program, including, but | 5 | | not limited to, the medical assistance program, for the | 6 | | provision of items or services for which payment may be | 7 | | made under such a program; | 8 | | (g) commits an act described in subsection (b) or | 9 | | (c) of Section 8A-3; | 10 | | (h) orders or prescribes a medical or other item or | 11 | | service during a period in which that person was | 12 | | excluded from the medical assistance program, in the | 13 | | case where the person knows or should know that a claim | 14 | | for such medical or other item or service will be made | 15 | | under such a program; | 16 | | (i) knowingly makes, uses, or causes to be made or | 17 | | used, a false record or statement material to a false | 18 | | or fraudulent claim to obtain payment or other benefit | 19 | | from the medical assistance program; | 20 | | (j) knowingly makes or causes to be made any false | 21 | | statement, omission, or misrepresentation of a | 22 | | material fact in any application, bid, or contract to | 23 | | participate or enroll as a provider of services under | 24 | | the medical assistance program; | 25 | | (k) fails to grant timely access, upon reasonable | 26 | | request (as defined by the Department) to the |
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| 1 | | Department or Department Inspector General, for the | 2 | | purpose of audits, investigations, evaluations, or | 3 | | other statutory functions of the Inspector General; or | 4 | | (l) knows of any overpayment and does not report | 5 | | and return the overpayment to the Department; | 6 | | shall be subject, in addition to any other penalties that | 7 | | may be prescribed by law, to a civil monetary penalty of | 8 | | not more than $10,000 for each item or service (or, in | 9 | | cases under item (c), $15,000 for each individual with | 10 | | respect to whom false or misleading information was given; | 11 | | in cases under item (d), $10,000 for each day the | 12 | | prohibited relationship occurs; in cases under item (g), | 13 | | $50,000 for each such act; in cases under item (h), $50,000 | 14 | | for each order or prescription; in cases under paragraphs | 15 | | (i) or (j), $50,000 for each false record or statement; or | 16 | | in cases under item (k), $15,000 for each day of the | 17 | | failure described in such item). In addition, such a person | 18 | | shall be subject to an assessment of not more than 3 times | 19 | | the amount claimed for each such item or service in lieu of | 20 | | damages sustained by the Department because of such claim | 21 | | (or, in the case of item (g), damages of not more than 3 | 22 | | times the total amount of remuneration offered, paid, | 23 | | solicited, or received, with regard to whether a portion of | 24 | | such remuneration was offered, paid, solicited, or | 25 | | received for a lawful purpose). In addition, the Director | 26 | | or his or her designee may make a determination in the same |
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| 1 | | proceeding to terminate, suspend, bar, or exclude the | 2 | | person from participation in the medical assistance | 3 | | program. | 4 | | (3) The Illinois Department may seek the civil monetary | 5 | | penalties or termination, suspension, barment, or | 6 | | exclusion identified in this subsection (E-5). Prior to the | 7 | | imposition of any penalties or sanctions, the affected | 8 | | individual, entity, or vendor shall be afforded an | 9 | | opportunity for a hearing after reasonable notice. The | 10 | | Department shall establish hearing procedures by rule. | 11 | | Any final order, decision, or other determination | 12 | | made, issued, or executed by the Director under the | 13 | | provisions of this subsection, whereby an individual, | 14 | | entity, or vendor is aggrieved, shall be subject to review | 15 | | in accordance with the provisions of the Administrative | 16 | | Review Law, and the rules adopted pursuant thereto, which | 17 | | shall apply to and govern all proceedings for the judicial | 18 | | review of final administrative decisions of the Director. | 19 | | (F) The Illinois Department may withhold payments to any | 20 | | vendor
or alternate payee prior to or during the pendency of | 21 | | any audit or proceeding under this Section, and through the | 22 | | pendency of any administrative appeal or administrative review | 23 | | by any court proceeding. The Illinois Department shall
state by | 24 | | rule with as much specificity as practicable the conditions
| 25 | | under which payments will not be withheld under this Section. | 26 | | Payments may be denied for bills
submitted with service dates |
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| 1 | | occurring during the pendency of a
proceeding, after a final | 2 | | decision has been rendered, or after the conclusion of any | 3 | | administrative appeal, where the final administrative decision | 4 | | is to terminate, exclude, or suspend
eligibility to participate | 5 | | in the medical assistance program. The
Illinois Department | 6 | | shall state by rule with as much specificity as
practicable the | 7 | | conditions under which payments will not be denied for
such | 8 | | bills.
The Illinois
Department shall state by rule a process | 9 | | and criteria by
which a vendor or alternate payee may request | 10 | | full or partial release of payments withheld under
this | 11 | | subsection. The Department must complete a proceeding under | 12 | | this Section
in a timely manner.
| 13 | | Notwithstanding recovery allowed under subsection (E) or | 14 | | this subsection (F), the Illinois Department may withhold | 15 | | payments to any vendor or alternate payee who is not properly | 16 | | licensed, certified, or in compliance with State or federal | 17 | | agency regulations. Payments may be denied for bills submitted | 18 | | with service dates occurring during the period of time that a | 19 | | vendor is not properly licensed, certified, or in compliance | 20 | | with State or federal regulations. Facilities licensed under
| 21 | | the Nursing Home Care Act shall have payments denied or
| 22 | | withheld pursuant to subsection (I) of this Section. | 23 | | (F-5) The Illinois Department may temporarily withhold | 24 | | payments to
a vendor or alternate payee if any of the following | 25 | | individuals have been indicted or
otherwise charged under a law | 26 | | of the United States or this or any other state
with an offense |
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| 1 | | that is based on alleged fraud or willful
misrepresentation on | 2 | | the part of the individual related to (i) the medical
| 3 | | assistance program under Article V of this Code, (ii) a federal | 4 | | or another state's medical assistance
or health care program, | 5 | | or (iii) the provision of health care services:
| 6 | | (1) If the vendor or alternate payee is a corporation: | 7 | | an officer of the corporation
or an individual who owns, | 8 | | either directly or indirectly, 5% or more
of the shares of | 9 | | stock or other evidence of ownership of the
corporation.
| 10 | | (2) If the vendor is a sole proprietorship: the owner | 11 | | of the sole
proprietorship.
| 12 | | (3) If the vendor or alternate payee is a partnership: | 13 | | a partner in the partnership.
| 14 | | (4) If the vendor or alternate payee is any other | 15 | | business entity authorized by law
to transact business in | 16 | | this State: an officer of the entity or an
individual who | 17 | | owns, either directly or indirectly, 5% or more of the
| 18 | | evidences of ownership of the entity.
| 19 | | If the Illinois Department withholds payments to a vendor | 20 | | or alternate payee under this
subsection, the Department shall | 21 | | not release those payments to the vendor
or alternate payee
| 22 | | while any criminal proceeding related to the indictment or | 23 | | charge is pending
unless the Department determines that there | 24 | | is good cause to release the
payments before completion of the | 25 | | proceeding. If the indictment or charge
results in the | 26 | | individual's conviction, the Illinois Department shall retain
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| 1 | | all withheld
payments, which shall be considered forfeited to | 2 | | the Department. If the
indictment or charge does not result in | 3 | | the individual's conviction, the
Illinois Department
shall | 4 | | release to the vendor or alternate payee all withheld payments.
| 5 | | (F-10) If the Illinois Department establishes that the | 6 | | vendor or alternate payee owes a debt to the Illinois | 7 | | Department, and the vendor or alternate payee subsequently | 8 | | fails to pay or make satisfactory payment arrangements with the | 9 | | Illinois Department for the debt owed, the Illinois Department | 10 | | may seek all remedies available under the law of this State to | 11 | | recover the debt, including, but not limited to, wage | 12 | | garnishment or the filing of claims or liens against the vendor | 13 | | or alternate payee. | 14 | | (F-15) Enforcement of judgment. | 15 | | (1) Any fine, recovery amount, other sanction, or costs | 16 | | imposed, or part of any fine, recovery amount, other | 17 | | sanction, or cost imposed, remaining unpaid after the | 18 | | exhaustion of or the failure to exhaust judicial review | 19 | | procedures under the Illinois Administrative Review Law is | 20 | | a debt due and owing the State and may be collected using | 21 | | all remedies available under the law. | 22 | | (2) After expiration of the period in which judicial | 23 | | review under the Illinois Administrative Review Law may be | 24 | | sought for a final administrative decision, unless stayed | 25 | | by a court of competent jurisdiction, the findings, | 26 | | decision, and order of the Director may be enforced in the |
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| 1 | | same manner as a judgment entered by a court of competent | 2 | | jurisdiction. | 3 | | (3) In any case in which any person or entity has | 4 | | failed to comply with a judgment ordering or imposing any | 5 | | fine or other sanction, any expenses incurred by the | 6 | | Illinois Department to enforce the judgment, including, | 7 | | but not limited to, attorney's fees, court costs, and costs | 8 | | related to property demolition or foreclosure, after they | 9 | | are fixed by a court of competent jurisdiction or the | 10 | | Director, shall be a debt due and owing the State and may | 11 | | be collected in accordance with applicable law. Prior to | 12 | | any expenses being fixed by a final administrative decision | 13 | | pursuant to this subsection (F-15), the Illinois | 14 | | Department shall provide notice to the individual or entity | 15 | | that states that the individual or entity shall appear at a | 16 | | hearing before the administrative hearing officer to | 17 | | determine whether the individual or entity has failed to | 18 | | comply with the judgment. The notice shall set the date for | 19 | | such a hearing, which shall not be less than 7 days from | 20 | | the date that notice is served. If notice is served by | 21 | | mail, the 7-day period shall begin to run on the date that | 22 | | the notice was deposited in the mail. | 23 | | (4) Upon being recorded in the manner required by | 24 | | Article XII of the Code of Civil Procedure or by the | 25 | | Uniform Commercial Code, a lien shall be imposed on the | 26 | | real estate or personal estate, or both, of the individual |
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| 1 | | or entity in the amount of any debt due and owing the State | 2 | | under this Section. The lien may be enforced in the same | 3 | | manner as a judgment of a court of competent jurisdiction. | 4 | | A lien shall attach to all property and assets of such | 5 | | person, firm, corporation, association, agency, | 6 | | institution, or other legal entity until the judgment is | 7 | | satisfied. | 8 | | (5) The Director may set aside any judgment entered by
| 9 | | default and set a new hearing date upon a petition filed at
| 10 | | any time (i) if the petitioner's failure to appear at the
| 11 | | hearing was for good cause, or (ii) if the petitioner
| 12 | | established that the Department did not provide proper
| 13 | | service of process. If any judgment is set aside pursuant
| 14 | | to this paragraph (5), the hearing officer shall have
| 15 | | authority to enter an order extinguishing any lien which
| 16 | | has been recorded for any debt due and owing the Illinois
| 17 | | Department as a result of the vacated default judgment. | 18 | | (G) The provisions of the Administrative Review Law, as now | 19 | | or hereafter
amended, and the rules adopted pursuant
thereto, | 20 | | shall apply to and govern all proceedings for the judicial
| 21 | | review of final administrative decisions of the Illinois | 22 | | Department
under this Section. The term "administrative | 23 | | decision" is defined as in
Section 3-101 of the Code of Civil | 24 | | Procedure.
| 25 | | (G-5) Vendors who pose a risk of fraud, waste, abuse, or | 26 | | harm.
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| 1 | | (1) Notwithstanding any other provision in this | 2 | | Section, the Department may terminate, suspend, or exclude | 3 | | vendors who pose a risk of fraud, waste, abuse, or harm | 4 | | from
participation in the medical assistance program prior
| 5 | | to an evidentiary hearing but after reasonable notice and | 6 | | opportunity to
respond as established by the Department by | 7 | | rule.
| 8 | | (2) Vendors who pose a risk of fraud, waste, abuse, or | 9 | | harm shall submit to a fingerprint-based criminal
| 10 | | background check on current and future information | 11 | | available in the State
system and current information | 12 | | available through the Federal Bureau of
Investigation's | 13 | | system by submitting all necessary fees and information in | 14 | | the
form and manner
prescribed by the Department of State | 15 | | Police. The following individuals shall
be subject to the | 16 | | check:
| 17 | | (A) In the case of a vendor that is a corporation, | 18 | | every shareholder
who owns, directly or indirectly, 5% | 19 | | or more of the outstanding shares of
the corporation.
| 20 | | (B) In the case of a vendor that is a partnership, | 21 | | every partner.
| 22 | | (C) In the case of a vendor that is a sole | 23 | | proprietorship, the sole
proprietor.
| 24 | | (D) Each officer or manager of the vendor.
| 25 | | Each such vendor shall be responsible for payment of | 26 | | the cost of the
criminal background check.
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| 1 | | (3) Vendors who pose a risk of fraud, waste, abuse, or | 2 | | harm may be
required to post a surety bond. The Department | 3 | | shall establish, by rule, the
criteria and requirements for | 4 | | determining when a surety bond must be posted and
the value | 5 | | of the bond.
| 6 | | (4) The Department, or its agents, may refuse to accept | 7 | | requests for authorization from specific vendors who pose a | 8 | | risk of fraud, waste, abuse, or harm, including | 9 | | prior-approval and
post-approval requests, if:
| 10 | | (A) the Department has initiated a notice of | 11 | | termination, suspension, or exclusion of the
vendor | 12 | | from participation in the medical assistance program; | 13 | | or
| 14 | | (B) the Department has issued notification of its | 15 | | withholding of
payments pursuant to subsection (F-5) | 16 | | of this Section; or
| 17 | | (C) the Department has issued a notification of its | 18 | | withholding of
payments due to reliable evidence of | 19 | | fraud or willful misrepresentation
pending | 20 | | investigation.
| 21 | | (5) As used in this subsection, the following terms are | 22 | | defined as follows: | 23 | | (A) "Fraud" means an intentional deception or | 24 | | misrepresentation made by a person with the knowledge | 25 | | that the deception could result in some unauthorized | 26 | | benefit to himself or herself or some other person. It |
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| 1 | | includes any act that constitutes fraud under | 2 | | applicable federal or State law. | 3 | | (B) "Abuse" means provider practices that are | 4 | | inconsistent with sound fiscal, business, or medical | 5 | | practices and that result in an unnecessary cost to the | 6 | | medical assistance program or in reimbursement for | 7 | | services that are not medically necessary or that fail | 8 | | to meet professionally recognized standards for health | 9 | | care. It also includes recipient practices that result | 10 | | in unnecessary cost to the medical assistance program. | 11 | | Abuse does not include diagnostic or therapeutic | 12 | | measures conducted primarily as a safeguard against | 13 | | possible vendor liability. | 14 | | (C) "Waste" means the unintentional misuse of | 15 | | medical assistance resources, resulting in unnecessary | 16 | | cost to the medical assistance program. Waste does not | 17 | | include diagnostic or therapeutic measures conducted | 18 | | primarily as a safeguard against possible vendor | 19 | | liability. | 20 | | (D) "Harm" means physical, mental, or monetary | 21 | | damage to recipients or to the medical assistance | 22 | | program. | 23 | | (G-6) The Illinois Department, upon making a determination | 24 | | based upon information in the possession of the Illinois | 25 | | Department that continuation of participation in the medical | 26 | | assistance program by a vendor would constitute an immediate |
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| 1 | | danger to the public, may immediately suspend such vendor's | 2 | | participation in the medical assistance program without a | 3 | | hearing. In instances in which the Illinois Department | 4 | | immediately suspends the medical assistance program | 5 | | participation of a vendor under this Section, a hearing upon | 6 | | the vendor's participation must be convened by the Illinois | 7 | | Department within 15 days after such suspension and completed | 8 | | without appreciable delay. Such hearing shall be held to | 9 | | determine whether to recommend to the Director that the | 10 | | vendor's medical assistance program participation be denied, | 11 | | terminated, suspended, placed on provisional status, or | 12 | | reinstated. In the hearing, any evidence relevant to the vendor | 13 | | constituting an immediate danger to the public may be | 14 | | introduced against such vendor; provided, however, that the | 15 | | vendor, or his or her counsel, shall have the opportunity to | 16 | | discredit, impeach, and submit evidence rebutting such | 17 | | evidence. | 18 | | (H) Nothing contained in this Code shall in any way limit | 19 | | or
otherwise impair the authority or power of any State agency | 20 | | responsible
for licensing of vendors.
| 21 | | (I) Based on a finding of noncompliance on the part of a | 22 | | nursing home with
any requirement for certification under Title | 23 | | XVIII or XIX of the Social
Security Act (42 U.S.C. Sec. 1395 et | 24 | | seq. or 42 U.S.C. Sec. 1396 et seq.), the
Illinois Department | 25 | | may impose one or more of the following remedies after
notice | 26 | | to the facility:
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| 1 | | (1) Termination of the provider agreement.
| 2 | | (2) Temporary management.
| 3 | | (3) Denial of payment for new admissions.
| 4 | | (4) Civil money penalties.
| 5 | | (5) Closure of the facility in emergency situations or | 6 | | transfer of
residents, or both.
| 7 | | (6) State monitoring.
| 8 | | (7) Denial of all payments when the U.S. Department of | 9 | | Health and Human Services has
imposed this sanction.
| 10 | | The Illinois Department shall by rule establish criteria | 11 | | governing continued
payments to a nursing facility subsequent | 12 | | to termination of the facility's
provider agreement if, in the | 13 | | sole discretion of the Illinois Department,
circumstances | 14 | | affecting the health, safety, and welfare of the facility's
| 15 | | residents require those continued payments. The Illinois | 16 | | Department may
condition those continued payments on the | 17 | | appointment of temporary management,
sale of the facility to | 18 | | new owners or operators, or other
arrangements that the | 19 | | Illinois Department determines best serve the needs of
the | 20 | | facility's residents.
| 21 | | Except in the case of a facility that has a right to a | 22 | | hearing on the finding
of noncompliance before an agency of the | 23 | | federal government, a facility may
request a hearing before a | 24 | | State agency on any finding of noncompliance within
60 days | 25 | | after the notice of the intent to impose a remedy. Except in | 26 | | the case
of civil money penalties, a request for a hearing |
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| 1 | | shall not delay imposition of
the penalty. The choice of | 2 | | remedies is not appealable at a hearing. The level
of | 3 | | noncompliance may be challenged only in the case of a civil | 4 | | money penalty.
The Illinois Department shall provide by rule | 5 | | for the State agency that will
conduct the evidentiary | 6 | | hearings.
| 7 | | The Illinois Department may collect interest on unpaid | 8 | | civil money penalties.
| 9 | | The Illinois Department may adopt all rules necessary to | 10 | | implement this
subsection (I).
| 11 | | (J) The Illinois Department, by rule, may permit individual | 12 | | practitioners to designate that Department payments that may be | 13 | | due the practitioner be made to an alternate payee or alternate | 14 | | payees. | 15 | | (a) Such alternate payee or alternate payees shall be | 16 | | required to register as an alternate payee in the Medical | 17 | | Assistance Program with the Illinois Department. | 18 | | (b) If a practitioner designates an alternate payee, | 19 | | the alternate payee and practitioner shall be jointly and | 20 | | severally liable to the Department for payments made to the | 21 | | alternate payee. Pursuant to subsection (E) of this | 22 | | Section, any Department action to suspend or deny payment | 23 | | or recover money or overpayments from an alternate payee | 24 | | shall be subject to an administrative hearing. | 25 | | (c) Registration as an alternate payee or alternate | 26 | | payees in the Illinois Medical Assistance Program shall be |
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| 1 | | conditional. At any time, the Illinois Department may deny | 2 | | or cancel any alternate payee's registration in the | 3 | | Illinois Medical Assistance Program without cause. Any | 4 | | such denial or cancellation is not subject to an | 5 | | administrative hearing. | 6 | | (d) The Illinois Department may seek a revocation of | 7 | | any alternate payee, and all owners, officers, and | 8 | | individuals with management responsibility for such | 9 | | alternate payee shall be permanently prohibited from | 10 | | participating as an owner, an officer, or an individual | 11 | | with management responsibility with an alternate payee in | 12 | | the Illinois Medical Assistance Program, if after | 13 | | reasonable notice and opportunity for a hearing the | 14 | | Illinois Department finds that: | 15 | | (1) the alternate payee is not complying with the | 16 | | Department's policy or rules and regulations, or with | 17 | | the terms and conditions prescribed by the Illinois | 18 | | Department in its alternate payee registration | 19 | | agreement; or | 20 | | (2) the alternate payee has failed to keep or make | 21 | | available for inspection, audit, or copying, after | 22 | | receiving a written request from the Illinois | 23 | | Department, such records regarding payments claimed as | 24 | | an alternate payee; or | 25 | | (3) the alternate payee has failed to furnish any | 26 | | information requested by the Illinois Department |
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| 1 | | regarding payments claimed as an alternate payee; or | 2 | | (4) the alternate payee has knowingly made, or | 3 | | caused to be made, any false statement or | 4 | | representation of a material fact in connection with | 5 | | the administration of the Illinois Medical Assistance | 6 | | Program; or | 7 | | (5) the alternate payee, a person with management | 8 | | responsibility for an alternate payee, an officer or | 9 | | person owning, either directly or indirectly, 5% or | 10 | | more of the shares of stock or other evidences of | 11 | | ownership in a corporate alternate payee, or a partner | 12 | | in a partnership which is an alternate payee: | 13 | | (a) was previously terminated, suspended, or | 14 | | excluded from participation as a vendor in the | 15 | | Illinois Medical Assistance Program, or was | 16 | | previously revoked as an alternate payee in the | 17 | | Illinois Medical Assistance Program, or was | 18 | | terminated, suspended, or excluded from | 19 | | participation as a vendor in a medical assistance | 20 | | program in another state that is of the same kind | 21 | | as the program of medical assistance provided | 22 | | under Article V of this Code; or | 23 | | (b) was a person with management | 24 | | responsibility for a vendor previously terminated, | 25 | | suspended, or excluded from participation as a | 26 | | vendor in the Illinois Medical Assistance Program, |
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| 1 | | or was previously revoked as an alternate payee in | 2 | | the Illinois Medical Assistance Program, or was | 3 | | terminated, suspended, or excluded from | 4 | | participation as a vendor in a medical assistance | 5 | | program in another state that is of the same kind | 6 | | as the program of medical assistance provided | 7 | | under Article V of this Code, during the time of | 8 | | conduct which was the basis for that vendor's | 9 | | termination, suspension, or exclusion or alternate | 10 | | payee's revocation; or | 11 | | (c) was an officer, or person owning, either | 12 | | directly or indirectly, 5% or more of the shares of | 13 | | stock or other evidences of ownership in a | 14 | | corporate vendor previously terminated, suspended, | 15 | | or excluded from participation as a vendor in the | 16 | | Illinois Medical Assistance Program, or was | 17 | | previously revoked as an alternate payee in the | 18 | | Illinois Medical Assistance Program, or was | 19 | | terminated, suspended, or excluded from | 20 | | participation as a vendor in a medical assistance | 21 | | program in another state that is of the same kind | 22 | | as the program of medical assistance provided | 23 | | under Article V of this Code, during the time of | 24 | | conduct which was the basis for that vendor's | 25 | | termination, suspension, or exclusion; or | 26 | | (d) was an owner of a sole proprietorship or |
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| 1 | | partner in a partnership previously terminated, | 2 | | suspended, or excluded from participation as a | 3 | | vendor in the Illinois Medical Assistance Program, | 4 | | or was previously revoked as an alternate payee in | 5 | | the Illinois Medical Assistance Program, or was | 6 | | terminated, suspended, or excluded from | 7 | | participation as a vendor in a medical assistance | 8 | | program in another state that is of the same kind | 9 | | as the program of medical assistance provided | 10 | | under Article V of this Code, during the time of | 11 | | conduct which was the basis for that vendor's | 12 | | termination, suspension, or exclusion or alternate | 13 | | payee's revocation; or | 14 | | (6) the alternate payee, a person with management | 15 | | responsibility for an alternate payee, an officer or | 16 | | person owning, either directly or indirectly, 5% or | 17 | | more of the shares of stock or other evidences of | 18 | | ownership in a corporate alternate payee, or a partner | 19 | | in a partnership which is an alternate payee: | 20 | | (a) has engaged in conduct prohibited by | 21 | | applicable federal or State law or regulation | 22 | | relating to the Illinois Medical Assistance | 23 | | Program; or | 24 | | (b) was a person with management | 25 | | responsibility for a vendor or alternate payee at | 26 | | the time that the vendor or alternate payee engaged |
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| 1 | | in practices prohibited by applicable federal or | 2 | | State law or regulation relating to the Illinois | 3 | | Medical Assistance Program; or | 4 | | (c) was an officer, or person owning, either | 5 | | directly or indirectly, 5% or more of the shares of | 6 | | stock or other evidences of ownership in a vendor | 7 | | or alternate payee at the time such vendor or | 8 | | alternate payee engaged in practices prohibited by | 9 | | applicable federal or State law or regulation | 10 | | relating to the Illinois Medical Assistance | 11 | | Program; or | 12 | | (d) was an owner of a sole proprietorship or | 13 | | partner in a partnership which was a vendor or | 14 | | alternate payee at the time such vendor or | 15 | | alternate payee engaged in practices prohibited by | 16 | | applicable federal or State law or regulation | 17 | | relating to the Illinois Medical Assistance | 18 | | Program; or | 19 | | (7) the direct or indirect ownership of the vendor | 20 | | or alternate payee (including the ownership of a vendor | 21 | | or alternate payee that is a partner's interest in a | 22 | | vendor or alternate payee, or ownership of 5% or more | 23 | | of the shares of stock or other evidences of ownership | 24 | | in a corporate vendor or alternate payee) has been | 25 | | transferred by an individual who is terminated, | 26 | | suspended, or excluded or barred from participating as |
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| 1 | | a vendor or is prohibited or revoked as an alternate | 2 | | payee to the individual's spouse, child, brother, | 3 | | sister, parent, grandparent, grandchild, uncle, aunt, | 4 | | niece, nephew, cousin, or relative by marriage. | 5 | | (K) The Illinois Department of Healthcare and Family | 6 | | Services may withhold payments, in whole or in part, to a | 7 | | provider or alternate payee where there is credible evidence, | 8 | | received from State or federal law enforcement or federal | 9 | | oversight agencies or from the results of a preliminary | 10 | | Department audit, that the circumstances giving rise to the | 11 | | need for a withholding of payments may involve fraud or willful | 12 | | misrepresentation under the Illinois Medical Assistance | 13 | | program. The Department shall by rule define what constitutes | 14 | | "credible" evidence for purposes of this subsection. The | 15 | | Department may withhold payments without first notifying the | 16 | | provider or alternate payee of its intention to withhold such | 17 | | payments. A provider or alternate payee may request a | 18 | | reconsideration of payment withholding, and the Department | 19 | | must grant such a request. The Department shall state by rule a | 20 | | process and criteria by which a provider or alternate payee may | 21 | | request full or partial release of payments withheld under this | 22 | | subsection. This request may be made at any time after the | 23 | | Department first withholds such payments. | 24 | | (a) The Illinois Department must send notice of its
| 25 | | withholding of program payments within 5 days of taking | 26 | | such action. The notice must set forth the general |
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| 1 | | allegations as to the nature of the withholding action, but | 2 | | need not disclose any specific information concerning its | 3 | | ongoing investigation. The notice must do all of the | 4 | | following: | 5 | | (1) State that payments are being withheld in
| 6 | | accordance with this subsection. | 7 | | (2) State that the withholding is for a temporary
| 8 | | period, as stated in paragraph (b) of this
subsection, | 9 | | and cite the circumstances under which
withholding | 10 | | will be terminated. | 11 | | (3) Specify, when appropriate, which type or types
| 12 | | of Medicaid claims withholding is effective. | 13 | | (4) Inform the provider or alternate payee of the
| 14 | | right to submit written evidence for reconsideration | 15 | | of the withholding by
the Illinois Department. | 16 | | (5) Inform the provider or alternate payee that a | 17 | | written request may be made to the Illinois Department | 18 | | for full or partial release of withheld payments and | 19 | | that such requests may be made at any time after the | 20 | | Department first withholds such payments.
| 21 | | (b) All withholding-of-payment actions under this
| 22 | | subsection shall be temporary and shall not continue after | 23 | | any of the following: | 24 | | (1) The Illinois Department or the prosecuting
| 25 | | authorities determine that there is insufficient
| 26 | | evidence of fraud or willful misrepresentation by the
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| 1 | | provider or alternate payee. | 2 | | (2) Legal proceedings related to the provider's or
| 3 | | alternate payee's alleged fraud, willful
| 4 | | misrepresentation, violations of this Act, or
| 5 | | violations of the Illinois Department's administrative
| 6 | | rules are completed. | 7 | | (3) The withholding of payments for a period of 3 | 8 | | years.
| 9 | | (c) The Illinois Department may adopt all rules | 10 | | necessary
to implement this subsection (K).
| 11 | | (K-5) The Illinois Department may withhold payments, in | 12 | | whole or in part, to a provider or alternate payee upon | 13 | | initiation of an audit, quality of care review, investigation | 14 | | when there is a credible allegation of fraud, or the provider | 15 | | or alternate payee demonstrating a clear failure to cooperate | 16 | | with the Illinois Department such that the circumstances give | 17 | | rise to the need for a withholding of payments. As used in this | 18 | | subsection, "credible allegation" is defined to include an | 19 | | allegation from any source, including, but not limited to, | 20 | | fraud hotline complaints, claims data mining, patterns | 21 | | identified through provider audits, civil actions filed under | 22 | | the Illinois False Claims Act, and law enforcement | 23 | | investigations. An allegation is considered to be credible when | 24 | | it has indicia of reliability. The Illinois Department may | 25 | | withhold payments without first notifying the provider or | 26 | | alternate payee of its intention to withhold such payments. A |
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| 1 | | provider or alternate payee may request a hearing or a | 2 | | reconsideration of payment withholding, and the Illinois | 3 | | Department must grant such a request. The Illinois Department | 4 | | shall state by rule a process and criteria by which a provider | 5 | | or alternate payee may request a hearing or a reconsideration | 6 | | for the full or partial release of payments withheld under this | 7 | | subsection. This request may be made at any time after the | 8 | | Illinois Department first withholds such payments. | 9 | | (a) The Illinois Department must send notice of its | 10 | | withholding of program payments within 5 days of taking | 11 | | such action. The notice must set forth the general | 12 | | allegations as to the nature of the withholding action but | 13 | | need not disclose any specific information concerning its | 14 | | ongoing investigation. The notice must do all of the | 15 | | following: | 16 | | (1) State that payments are being withheld in | 17 | | accordance with this subsection. | 18 | | (2) State that the withholding is for a temporary | 19 | | period, as stated in paragraph (b) of this subsection, | 20 | | and cite the circumstances under which withholding | 21 | | will be terminated. | 22 | | (3) Specify, when appropriate, which type or types | 23 | | of claims are withheld. | 24 | | (4) Inform the provider or alternate payee of the | 25 | | right to request a hearing or a reconsideration of the | 26 | | withholding by the Illinois Department, including the |
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| 1 | | ability to submit written evidence. | 2 | | (5) Inform the provider or alternate payee that a | 3 | | written request may be made to the Illinois Department | 4 | | for a hearing or a reconsideration for the full or | 5 | | partial release of withheld payments and that such | 6 | | requests may be made at any time after the Illinois | 7 | | Department first withholds such payments. | 8 | | (b) All withholding of payment actions under this | 9 | | subsection shall be temporary and shall not continue after | 10 | | any of the following: | 11 | | (1) The Illinois Department determines that there | 12 | | is insufficient evidence of fraud, or the provider or | 13 | | alternate payee demonstrates clear cooperation with | 14 | | the Illinois Department, as determined by the Illinois | 15 | | Department, such that the circumstances do not give | 16 | | rise to the need for withholding of payments; or | 17 | | (2) The withholding of payments has lasted for a | 18 | | period in excess of 3 years. | 19 | | (c) The Illinois Department may adopt all rules | 20 | | necessary to implement this subsection (K-5). | 21 | | (L) The Illinois Department shall establish a protocol to | 22 | | enable health care providers to disclose an actual or potential | 23 | | violation of this Section pursuant to a self-referral | 24 | | disclosure protocol, referred to in this subsection as "the | 25 | | protocol". The protocol shall include direction for health care | 26 | | providers on a specific person, official, or office to whom |
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| 1 | | such disclosures shall be made. The Illinois Department shall | 2 | | post information on the protocol on the Illinois Department's | 3 | | public website. The Illinois Department may adopt rules | 4 | | necessary to implement this subsection (L). In addition to | 5 | | other factors that the Illinois Department finds appropriate, | 6 | | the Illinois Department may consider a health care provider's | 7 | | timely use or failure to use the protocol in considering the | 8 | | provider's failure to comply with this Code. | 9 | | (M) Notwithstanding any other provision of this Code, the | 10 | | Illinois Department, at its discretion, may exempt an entity | 11 | | licensed under the Nursing Home Care Act and the ID/DD | 12 | | Community Care Act from the provisions of subsections (A-15), | 13 | | (B), and (C) of this Section if the licensed entity is in | 14 | | receivership. | 15 | | (Source: P.A. 97-689, eff. 6-14-12; revised 8-3-12.)
| 16 | | Section 99. Effective date. This Act takes effect upon | 17 | | becoming law.
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