Full Text of SB1330 98th General Assembly
SB1330sam001 98TH GENERAL ASSEMBLY | Sen. Kwame Raoul Filed: 3/15/2013
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| 1 | | AMENDMENT TO SENATE BILL 1330
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1330 by replacing | 3 | | everything after the enacting clause with the following:
| 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:
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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, podiatrists and | 8 | | dentists setting forth the
terms and conditions applicable | 9 | | to the participation of each vendor
group in the program; | 10 | | 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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| 1 | | terminate the
eligibility
of any person, firm, corporation, | 2 | | association, agency, institution, or other
legal entity to | 3 | | participate as a vendor of goods or services to recipients
| 4 | | under the medical assistance program under Article V, or may
| 5 | | exclude any such person or entity from participation as such a
| 6 | | vendor, if, after reasonable
notice and opportunity for a | 7 | | hearing, the Illinois Department finds that the
vendor; a | 8 | | person with management responsibility for a vendor; an officer | 9 | | or
person owning, either directly or indirectly, 5% or more of | 10 | | the shares of stock
or other evidences of ownership in a | 11 | | corporate vendor; an owner of a sole
proprietorship that is a | 12 | | vendor; or a partner in a partnership that is a vendor
has been | 13 | | convicted of an offense based on fraud or willful
| 14 | | misrepresentation 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 | 26 | | terminate the eligibility of any person, firm, corporation, |
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| 1 | | association, agency, institution, or other legal entity to | 2 | | participate as a vendor of goods or services to recipients | 3 | | under the medical assistance program under Article V, or may
| 4 | | exclude any such person or entity from participation as such a
| 5 | | vendor, if, after reasonable notice and opportunity for a | 6 | | hearing, 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 | 9 | | indirectly, 5% or more of the shares of stock or other | 10 | | evidences of ownership in a corporate vendor, (iv) an owner of | 11 | | a sole proprietorship that is a vendor, or (v) a partner in a | 12 | | partnership that is a vendor has been convicted of an offense | 13 | | related 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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| 1 | | any person, firm, corporation, association, agency, | 2 | | institution, or other legal entity to participate as a vendor | 3 | | of goods or services to recipients under the medical assistance | 4 | | program under Article V if, after reasonable notice and | 5 | | opportunity 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 | 14 | | defined to include an allegation from any source, including, | 15 | | but not limited to, fraud hotline complaints, claims data | 16 | | mining, patterns identified through provider audits, civil | 17 | | actions filed under the Illinois False Claims Act, and law | 18 | | enforcement investigations. An allegation is considered to be | 19 | | credible when it has indicia of reliability. | 20 | | (B) The Illinois Department shall deny, suspend or | 21 | | terminate the
eligibility of any person, firm, corporation, | 22 | | association, agency,
institution or other legal entity to | 23 | | participate as a vendor of goods or
services to recipients | 24 | | under the medical assistance program under
Article V, or may
| 25 | | exclude any such person or entity from participation as such a
| 26 | | vendor:
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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 | 10 | | of goods or services from
participation in the medical | 11 | | assistance program authorized by this
Article, a person with | 12 | | management responsibility for such vendor during
the time of | 13 | | any conduct which served as the basis for that vendor's
| 14 | | termination, suspension, or exclusion is barred from | 15 | | participation in the medical assistance
program.
| 16 | | Upon termination, suspension, or exclusion of a corporate | 17 | | vendor, the officers and persons
owning, directly or | 18 | | indirectly, 5% or more of the shares of stock or
other | 19 | | evidences of ownership in the vendor during the time of any
| 20 | | conduct which served as the basis for that vendor's | 21 | | termination, suspension, or exclusion are
barred from | 22 | | participation in the medical assistance program. A person who
| 23 | | owns, directly or indirectly, 5% or more of the shares of stock | 24 | | or other
evidences of ownership in a terminated, suspended, or | 25 | | excluded vendor may not transfer his or
her ownership interest | 26 | | in that vendor to his or her spouse, child, brother,
sister, |
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| 1 | | parent, grandparent, grandchild, uncle, aunt, niece, nephew, | 2 | | cousin, or
relative by marriage.
| 3 | | Upon termination, suspension, or exclusion of a sole | 4 | | proprietorship or partnership, the owner
or partners during the | 5 | | time of any conduct which served as the basis for
that vendor's | 6 | | termination, suspension, or exclusion are barred from | 7 | | participation in the medical
assistance program. The owner of a | 8 | | terminated, suspended, or excluded vendor that is a sole
| 9 | | proprietorship, and a partner in a terminated, suspended, or | 10 | | excluded vendor that is a partnership, may
not transfer his or | 11 | | her ownership or partnership interest in that vendor to his
or | 12 | | her spouse, child, brother, sister, parent, grandparent, | 13 | | grandchild, uncle,
aunt, niece, nephew, cousin, or relative by | 14 | | marriage.
| 15 | | A person who owns, directly or indirectly, 5% or more of | 16 | | the shares of stock or other evidences of ownership in a | 17 | | corporate or limited liability company vendor who owes a debt | 18 | | to the Department, if that vendor has not made payment | 19 | | arrangements acceptable to the Department, shall not transfer | 20 | | his or her ownership interest in that vendor, or vendor assets | 21 | | of any kind, to his or her spouse, child, brother, sister, | 22 | | parent, grandparent, grandchild, uncle, aunt, niece, nephew, | 23 | | cousin, or relative by marriage. | 24 | | Rules adopted by the Illinois Department to implement these
| 25 | | provisions shall specifically include a definition of the term
| 26 | | "management responsibility" as used in this Section. Such |
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| 1 | | definition
shall include, but not be limited to, typical job | 2 | | titles, and duties and
descriptions which will be considered as | 3 | | within the definition of
individuals with management | 4 | | responsibility for a provider.
| 5 | | A vendor or a prior vendor who has been terminated, | 6 | | excluded, or suspended from the medical assistance program, or | 7 | | from another state or federal medical assistance or health care | 8 | | program, and any individual currently or previously barred from | 9 | | the medical assistance program, or from another state or | 10 | | federal medical assistance or health care program, as a result | 11 | | of being an officer or a person owning, directly or indirectly, | 12 | | 5% or more of the shares of stock or other evidences of | 13 | | ownership in a corporate or limited liability company vendor | 14 | | during the time of any conduct which served as the basis for | 15 | | that vendor's termination, suspension, or exclusion, may be | 16 | | required to post a surety bond as part of a condition of | 17 | | enrollment or participation in the medical assistance program. | 18 | | The Illinois Department shall establish, by rule, the criteria | 19 | | and requirements for determining when a surety bond must be | 20 | | posted and the value of the bond. | 21 | | A vendor or a prior vendor who has a debt owed to the | 22 | | Illinois Department and any individual currently or previously | 23 | | barred from the medical assistance program, or from another | 24 | | state or federal medical assistance or health care program, as | 25 | | a result of being an officer or a person owning, directly or | 26 | | indirectly, 5% or more of the shares of stock or other |
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| 1 | | evidences of ownership in that corporate or limited liability | 2 | | company vendor during the time of any conduct which served as | 3 | | the basis for the debt, may be required to post a surety bond | 4 | | as part of a condition of enrollment or participation in the | 5 | | medical assistance program. The Illinois Department shall | 6 | | establish, by rule, the criteria and requirements for | 7 | | determining when a surety bond must be posted and the value of | 8 | | the bond. | 9 | | (D) If a vendor has been suspended from the medical | 10 | | assistance
program under Article V of the Code, the Director | 11 | | may require that such
vendor correct any deficiencies which | 12 | | served as the basis for the
suspension. The Director shall | 13 | | specify in the suspension order a specific
period of time, | 14 | | which shall not exceed one year from the date of the
order, | 15 | | during which a suspended vendor shall not be eligible to
| 16 | | participate. At the conclusion of the period of suspension the | 17 | | Director
shall reinstate such vendor, unless he finds that such | 18 | | vendor has not
corrected deficiencies upon which the suspension | 19 | | was based.
| 20 | | If a vendor has been terminated, suspended, or excluded | 21 | | from the medical assistance program
under Article V, such | 22 | | vendor shall be barred from participation for at
least one | 23 | | year, except that if a vendor has been terminated, suspended, | 24 | | or excluded based on a
conviction of a
violation of Article | 25 | | VIIIA or a conviction of a felony based on fraud or a
willful | 26 | | misrepresentation related to (i) the medical assistance |
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| 1 | | program under
Article V, (ii) a federal or another state's | 2 | | medical assistance or health care program, or (iii) the | 3 | | provision of health care services, then
the vendor shall be | 4 | | barred from participation for 5 years or for the length of
the | 5 | | vendor's sentence for that conviction, whichever is longer. At | 6 | | the end of
one year a vendor who has been terminated, | 7 | | suspended, or excluded
may apply for reinstatement to the | 8 | | program. Upon proper application to
be reinstated such vendor | 9 | | may be deemed eligible by the Director
providing that such | 10 | | vendor meets the requirements for eligibility under
this Code. | 11 | | If such vendor is deemed not eligible for
reinstatement, he
| 12 | | shall be barred from again applying for reinstatement for one | 13 | | year from the
date his application for reinstatement is denied.
| 14 | | A vendor whose termination, suspension, or exclusion from | 15 | | participation in the Illinois medical
assistance program under | 16 | | Article V was based solely on an action by a
governmental | 17 | | entity other than the Illinois Department may, upon | 18 | | reinstatement
by that governmental entity or upon reversal of | 19 | | the termination, suspension, or exclusion, apply for
| 20 | | rescission of the termination, suspension, or exclusion from | 21 | | participation in the Illinois medical
assistance program. Upon | 22 | | proper application for rescission, the vendor may be
deemed | 23 | | eligible by the Director if the vendor meets the requirements | 24 | | for
eligibility under this Code.
| 25 | | If a vendor has been terminated, suspended, or excluded and | 26 | | reinstated to the medical assistance
program under Article V |
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| 1 | | and the vendor is terminated, suspended, or excluded a second | 2 | | or subsequent
time from the medical assistance program, the | 3 | | vendor shall be barred from
participation for at least 2 years, | 4 | | except that if a vendor has been
terminated, suspended, or | 5 | | excluded a second time based on a
conviction of a violation of | 6 | | Article VIIIA or a conviction of a felony based on
fraud or a | 7 | | willful misrepresentation related to (i) the medical | 8 | | assistance
program under Article V, (ii) a federal or another | 9 | | state's medical assistance or health care program, or (iii) the | 10 | | provision of health care
services, then the vendor shall be | 11 | | barred from participation for life. At
the end of 2 years, a | 12 | | vendor who has
been terminated, suspended, or excluded may | 13 | | apply for reinstatement to the program. Upon application
to be | 14 | | reinstated, the vendor may be deemed eligible if the vendor | 15 | | meets the
requirements for eligibility under this Code. If the | 16 | | vendor is deemed not
eligible for reinstatement, the vendor | 17 | | shall be barred from again applying for
reinstatement for 2 | 18 | | years from the date the vendor's application for
reinstatement | 19 | | is denied.
| 20 | | (E) The Illinois Department may recover money improperly or
| 21 | | erroneously paid, or overpayments, either by setoff, crediting | 22 | | against
future billings or by requiring direct repayment to the | 23 | | Illinois
Department. The Illinois Department may suspend or | 24 | | deny payment, in whole or in part, if such payment would be | 25 | | improper 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 | | (2) Notwithstanding any other provision of law, if a | 2 | | vendor has the same taxpayer identification number | 3 | | (assigned under Section 6109 of the Internal Revenue Code | 4 | | of 1986) as is assigned to a vendor with past-due financial | 5 | | obligations to the Illinois Department, the Illinois | 6 | | Department may make any necessary adjustments to payments | 7 | | to that vendor in order to satisfy any past-due | 8 | | obligations, regardless of whether the vendor is assigned a | 9 | | different billing number under the medical assistance | 10 | | program.
| 11 | | If the Illinois Department establishes through an | 12 | | administrative
hearing that the overpayments resulted from the | 13 | | vendor
or alternate payee knowingly making, using, or causing | 14 | | to be made or used, a false record or statement to obtain | 15 | | payment or other benefit from the medical assistance program | 16 | | under Article V, the Department may
recover interest on the | 17 | | amount of the payment or other benefit at the rate of 5% per | 18 | | annum.
In addition to any other penalties that may be | 19 | | prescribed by law, such a vendor or alternate payee shall be | 20 | | subject to civil penalties consisting of an amount not to | 21 | | exceed 3 times the amount of payment or other benefit resulting | 22 | | from each such false record or statement, and the sum of $2,000 | 23 | | for each such false record or statement for payment or other | 24 | | benefit. For purposes of this paragraph,
"knowingly" means that | 25 | | a vendor or alternate payee with respect to information: (i) | 26 | | has
actual knowledge of the information, (ii) acts in |
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| 1 | | deliberate ignorance of the truth or falsity of the | 2 | | information, or (iii) acts in reckless disregard of the truth | 3 | | or falsity of the information. No proof of specific intent to | 4 | | defraud is required.
| 5 | | (E-5) Civil monetary penalties for improperly filed | 6 | | claims. | 7 | | (1) As used in this subsection (E-5): | 8 | | (a) "Knowingly" means that a person, with respect | 9 | | to
information:
(i) has actual knowledge of the | 10 | | information;
(ii) acts in deliberate ignorance of the | 11 | | truth or falsity of the
information; or
(iii) acts in | 12 | | reckless disregard of the truth or falsity of the
| 13 | | information. No proof of specific intent to defraud is | 14 | | required. | 15 | | (b) "Overpayment" means any funds that a person | 16 | | receives or
retains from the medical assistance | 17 | | program to which the person,
after applicable | 18 | | reconciliation, is not entitled under this Code. | 19 | | (c) "Remuneration" means the offer or transfer of | 20 | | items or
services for free or for other than fair | 21 | | market value by a
person; however, remuneration does | 22 | | not include items or services
of a nominal value of no | 23 | | more than $10 per item or service, or
$50 in the | 24 | | aggregate on an annual basis, or any other offer or
| 25 | | transfer of the items or services as determined by the
| 26 | | Department. |
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| 1 | | (d) "Should know" means that a person, with respect | 2 | | to
information:
(i) acts in deliberate ignorance of the | 3 | | truth or falsity
of the information; or
(ii) acts in | 4 | | reckless disregard of the truth or falsity of
the | 5 | | information. No proof of specific intent to defraud is | 6 | | required. | 7 | | (2) Any person (including a vendor, provider, | 8 | | organization, agency, or other entity, or an alternate | 9 | | payee thereof, but excluding a recipient) who: | 10 | | (a) knowingly presents or causes to be presented to | 11 | | an officer, employee, or agent of the Department or the | 12 | | State, a claim that the Department determines: | 13 | | (i) is for a medical or other item or service | 14 | | that the person knows or should know was not | 15 | | provided as claimed, including any person who | 16 | | engages in a pattern or practice of presenting or | 17 | | causing to be presented a claim for an item or | 18 | | service that is based on a code that the person | 19 | | knows or should know will result in a greater | 20 | | payment to the person than the code the person | 21 | | knows or should know is applicable to the item or | 22 | | service actually provided; | 23 | | (ii) is for a medical or other item or service | 24 | | and the person knows or should know that the claim | 25 | | is false or fraudulent; | 26 | | (iii) is presented for a physician's service, |
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| 1 | | or an item or service incident to a physician's | 2 | | service, by a person who knows or should know that | 3 | | the individual who furnished, or supervised the | 4 | | furnishing of, the service: | 5 | | (AA) was not licensed as a physician; | 6 | | (BB) was licensed as a physician but such | 7 | | license had been obtained through a | 8 | | misrepresentation of material fact (including | 9 | | cheating on an examination required for | 10 | | licensing); or | 11 | | (CC) represented to the patient at the | 12 | | time the service was furnished that the | 13 | | physician was certified in a medical specialty | 14 | | by a medical specialty board, when the | 15 | | individual was not so certified; | 16 | | (iv) is for a medical or other item or service | 17 | | furnished during a period in which the person was | 18 | | excluded from the medical assistance program or a | 19 | | federal or state health care program under which | 20 | | the claim
was made pursuant to applicable law; or | 21 | | (v) is for a pattern of medical or other items | 22 | | or services that a person knows or should know are | 23 | | not medically necessary; | 24 | | (b) knowingly presents or causes to be presented to | 25 | | any person a request for payment which is in violation | 26 | | of the conditions for receipt
of vendor payments under |
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| 1 | | the medical assistance program under Section 11-13 of | 2 | | this Code; | 3 | | (c) knowingly gives or causes to be given to any | 4 | | person, with respect to medical assistance program | 5 | | coverage of inpatient hospital services, information | 6 | | that he or she knows or should know is false or | 7 | | misleading, and that could reasonably be expected to | 8 | | influence the decision when to discharge such person or | 9 | | other individual from the hospital; | 10 | | (d) in the case of a person who is not an | 11 | | organization, agency, or other entity, is excluded | 12 | | from participating in the medical assistance
program | 13 | | or a federal or state health care program and who, at | 14 | | the time
of a violation of this subsection (E-5): | 15 | | (i) retains a direct or indirect ownership or | 16 | | control interest in an entity that is | 17 | | participating in the medical assistance program or | 18 | | a federal or state health care program, and who | 19 | | knows or should know of the action constituting the | 20 | | basis for the exclusion; or | 21 | | (ii) is an officer or managing employee of such | 22 | | an entity; | 23 | | (e) offers or transfers remuneration to any | 24 | | individual eligible for benefits under the medical | 25 | | assistance program that such person knows or should | 26 | | know is likely to influence such individual to order or |
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| 1 | | receive from a particular vendor, provider, | 2 | | practitioner, or supplier any item or service for which | 3 | | payment may be made, in whole or in part, under the | 4 | | medical assistance program; | 5 | | (f) arranges or contracts (by employment or | 6 | | otherwise) with an individual or entity that the person | 7 | | knows or should know is excluded from participation in | 8 | | the medical assistance program or a federal or
state | 9 | | health care program, for the provision of items or | 10 | | services for which payment may be made under such a | 11 | | program; | 12 | | (g) commits an act described in subsection (b) or | 13 | | (c) of Section 8A-3; | 14 | | (h) knowingly makes, uses, or causes to be made or | 15 | | used, a false record
or statement material to a false | 16 | | or fraudulent claim for payment for
items and services | 17 | | furnished under the medical assistance program; | 18 | | (i) fails to grant timely access, upon reasonable | 19 | | request (as defined
by the Department), to the | 20 | | Inspector General, for the purpose of
audits, | 21 | | investigations, evaluations, or other statutory | 22 | | functions of
the Inspector General of the Department; | 23 | | (j) orders or prescribes a medical or other item or | 24 | | service during a
period in which the person was | 25 | | excluded from the medical assistance
program or a | 26 | | federal or state health care program, in the case where
|
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| 1 | | the person knows or should know that a claim for such | 2 | | medical or other
item or service will be made under | 3 | | such a program; | 4 | | (k) knowingly makes or causes to be made any false | 5 | | statement, omission, or misrepresentation of a | 6 | | material fact in any application, bid, or contract to | 7 | | participate or enroll as a vendor or provider of | 8 | | services or a supplier under the medical assistance | 9 | | program; | 10 | | (l) knows of an overpayment and does not report and | 11 | | return the
overpayment to the Department; | 12 | | shall be subject, in addition to any other penalties that | 13 | | may be prescribed by law, to a civil money penalty of not | 14 | | more than $10,000
for each item or service (or, in cases | 15 | | under paragraph (c), $15,000
for each individual with | 16 | | respect to whom false or misleading
information was given; | 17 | | in cases under paragraph (d), $10,000 for
each day the | 18 | | prohibited relationship occurs; in cases under paragraph
| 19 | | (g), $50,000 for each such act; in cases under paragraph
| 20 | | (h), $50,000 for each false record or statement; in cases | 21 | | under
paragraph (i), $15,000 for each day of the failure | 22 | | described in such
paragraph; or in cases under paragraph | 23 | | (k), $50,000 for each false
statement, omission, or | 24 | | misrepresentation of a material fact). In
addition, such a | 25 | | person shall be subject to an assessment of not more
than 3 | 26 | | times the amount claimed for each such item or service in |
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| 1 | | lieu
of damages sustained by State or the Department | 2 | | because of such claim
(or, in cases under paragraph (g), | 3 | | damages of not more than 3 times
the total amount of | 4 | | remuneration offered, paid, solicited, or received,
| 5 | | without regard to whether a portion of such remuneration | 6 | | was offered,
paid, solicited, or received for a lawful | 7 | | purpose; or in cases under
paragraph (k), an assessment of | 8 | | not more than 3 times the total
amount claimed for each | 9 | | item or service for which payment was made
based upon the | 10 | | application, bid, or contract containing the false
| 11 | | statement, omission, or misrepresentation of a material | 12 | | fact). | 13 | | (3) In addition, the Department may make a | 14 | | determination in the
same proceeding to exclude, | 15 | | terminate, suspend, or bar the person from
participation in | 16 | | the medical assistance program. | 17 | | (4) Prior to the imposition of any penalties or | 18 | | sanctions, the affected
person shall be afforded an
| 19 | | opportunity for a hearing after reasonable notice. The
| 20 | | Department shall establish hearing procedures by rule. | 21 | | Any final order, decision, or other determination made, | 22 | | issued, or executed by the Director under the provisions of | 23 | | this subsection, whereby a person is aggrieved, shall be | 24 | | subject to review in accordance with the provisions of the | 25 | | Administrative Review Law, and the rules adopted pursuant | 26 | | thereto, which shall apply to and govern all proceedings for |
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| 1 | | the judicial review of final administrative decisions of the | 2 | | Director. | 3 | | (F) The Illinois Department may withhold payments to any | 4 | | vendor
or alternate payee prior to or during the pendency of | 5 | | any audit or proceeding under this Section, and through the | 6 | | pendency of any administrative appeal or administrative review | 7 | | by any court proceeding. The Illinois Department shall
state by | 8 | | rule with as much specificity as practicable the conditions
| 9 | | under which payments will not be withheld under this Section. | 10 | | Payments may be denied for bills
submitted with service dates | 11 | | occurring during the pendency of a
proceeding, after a final | 12 | | decision has been rendered, or after the conclusion of any | 13 | | administrative appeal, where the final administrative decision | 14 | | is to terminate, exclude, or suspend
eligibility to participate | 15 | | in the medical assistance program. The
Illinois Department | 16 | | shall state by rule with as much specificity as
practicable the | 17 | | conditions under which payments will not be denied for
such | 18 | | bills.
The Illinois
Department shall state by rule a process | 19 | | and criteria by
which a vendor or alternate payee may request | 20 | | full or partial release of payments withheld under
this | 21 | | subsection. The Department must complete a proceeding under | 22 | | this Section
in a timely manner.
| 23 | | Notwithstanding recovery allowed under subsection (E) or | 24 | | this subsection (F), the Illinois Department may withhold | 25 | | payments to any vendor or alternate payee who is not properly | 26 | | licensed, certified, or in compliance with State or federal |
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| 1 | | agency regulations. Payments may be denied for bills submitted | 2 | | with service dates occurring during the period of time that a | 3 | | vendor is not properly licensed, certified, or in compliance | 4 | | with State or federal regulations. Facilities licensed under
| 5 | | the Nursing Home Care Act shall have payments denied or
| 6 | | withheld pursuant to subsection (I) of this Section. | 7 | | (F-5) The Illinois Department may temporarily withhold | 8 | | payments to
a vendor or alternate payee if any of the following | 9 | | individuals have been indicted or
otherwise charged under a law | 10 | | of the United States or this or any other state
with an offense | 11 | | that is based on alleged fraud or willful
misrepresentation on | 12 | | the part of the individual related to (i) the medical
| 13 | | assistance program under Article V of this Code, (ii) a federal | 14 | | or another state's medical assistance
or health care program, | 15 | | or (iii) the provision of health care services:
| 16 | | (1) If the vendor or alternate payee is a corporation: | 17 | | an officer of the corporation
or an individual who owns, | 18 | | either directly or indirectly, 5% or more
of the shares of | 19 | | stock or other evidence of ownership of the
corporation.
| 20 | | (2) If the vendor is a sole proprietorship: the owner | 21 | | of the sole
proprietorship.
| 22 | | (3) If the vendor or alternate payee is a partnership: | 23 | | a partner in the partnership.
| 24 | | (4) If the vendor or alternate payee is any other | 25 | | business entity authorized by law
to transact business in | 26 | | this State: an officer of the entity or an
individual who |
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| 1 | | owns, either directly or indirectly, 5% or more of the
| 2 | | evidences of ownership of the entity.
| 3 | | If the Illinois Department withholds payments to a vendor | 4 | | or alternate payee under this
subsection, the Department shall | 5 | | not release those payments to the vendor
or alternate payee
| 6 | | while any criminal proceeding related to the indictment or | 7 | | charge is pending
unless the Department determines that there | 8 | | is good cause to release the
payments before completion of the | 9 | | proceeding. If the indictment or charge
results in the | 10 | | individual's conviction, the Illinois Department shall retain
| 11 | | all withheld
payments, which shall be considered forfeited to | 12 | | the Department. If the
indictment or charge does not result in | 13 | | the individual's conviction, the
Illinois Department
shall | 14 | | release to the vendor or alternate payee all withheld payments.
| 15 | | (F-10) If the Illinois Department establishes that the | 16 | | vendor or alternate payee owes a debt to the Illinois | 17 | | Department, and the vendor or alternate payee subsequently | 18 | | fails to pay or make satisfactory payment arrangements with the | 19 | | Illinois Department for the debt owed, the Illinois Department | 20 | | may seek all remedies available under the law of this State to | 21 | | recover the debt, including, but not limited to, wage | 22 | | garnishment or the filing of claims or liens against the vendor | 23 | | or alternate payee. | 24 | | (F-15) Enforcement of judgment. | 25 | | (1) Any fine, recovery amount, other sanction, or costs | 26 | | imposed, or part of any fine, recovery amount, other |
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| 1 | | sanction, or cost imposed, remaining unpaid after the | 2 | | exhaustion of or the failure to exhaust judicial review | 3 | | procedures under the Illinois Administrative Review Law is | 4 | | a debt due and owing the State and may be collected using | 5 | | all remedies available under the law. | 6 | | (2) After expiration of the period in which judicial | 7 | | review under the Illinois Administrative Review Law may be | 8 | | sought for a final administrative decision, unless stayed | 9 | | by a court of competent jurisdiction, the findings, | 10 | | decision, and order of the Director may be enforced in the | 11 | | same manner as a judgment entered by a court of competent | 12 | | jurisdiction. | 13 | | (3) In any case in which any person or entity has | 14 | | failed to comply with a judgment ordering or imposing any | 15 | | fine or other sanction, any expenses incurred by the | 16 | | Illinois Department to enforce the judgment, including, | 17 | | but not limited to, attorney's fees, court costs, and costs | 18 | | related to property demolition or foreclosure, after they | 19 | | are fixed by a court of competent jurisdiction or the | 20 | | Director, shall be a debt due and owing the State and may | 21 | | be collected in accordance with applicable law. Prior to | 22 | | any expenses being fixed by a final administrative decision | 23 | | pursuant to this subsection (F-15), the Illinois | 24 | | Department shall provide notice to the individual or entity | 25 | | that states that the individual or entity shall appear at a | 26 | | hearing before the administrative hearing officer to |
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| 1 | | determine whether the individual or entity has failed to | 2 | | comply with the judgment. The notice shall set the date for | 3 | | such a hearing, which shall not be less than 7 days from | 4 | | the date that notice is served. If notice is served by | 5 | | mail, the 7-day period shall begin to run on the date that | 6 | | the notice was deposited in the mail. | 7 | | (4) Upon being recorded in the manner required by | 8 | | Article XII of the Code of Civil Procedure or by the | 9 | | Uniform Commercial Code, a lien shall be imposed on the | 10 | | real estate or personal estate, or both, of the individual | 11 | | or entity in the amount of any debt due and owing the State | 12 | | under this Section. The lien may be enforced in the same | 13 | | manner as a judgment of a court of competent jurisdiction. | 14 | | A lien shall attach to all property and assets of such | 15 | | person, firm, corporation, association, agency, | 16 | | institution, or other legal entity until the judgment is | 17 | | satisfied. | 18 | | (5) The Director may set aside any judgment entered by
| 19 | | default and set a new hearing date upon a petition filed at
| 20 | | any time (i) if the petitioner's failure to appear at the
| 21 | | hearing was for good cause, or (ii) if the petitioner
| 22 | | established that the Department did not provide proper
| 23 | | service of process. If any judgment is set aside pursuant
| 24 | | to this paragraph (5), the hearing officer shall have
| 25 | | authority to enter an order extinguishing any lien which
| 26 | | has been recorded for any debt due and owing the Illinois
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| 1 | | Department as a result of the vacated default judgment. | 2 | | (G) The provisions of the Administrative Review Law, as now | 3 | | or hereafter
amended, and the rules adopted pursuant
thereto, | 4 | | shall apply to and govern all proceedings for the judicial
| 5 | | review of final administrative decisions of the Illinois | 6 | | Department
under this Section. The term "administrative | 7 | | decision" is defined as in
Section 3-101 of the Code of Civil | 8 | | Procedure.
| 9 | | (G-5) Vendors who pose a risk of fraud, waste, abuse, or | 10 | | harm.
| 11 | | (1) Notwithstanding any other provision in this | 12 | | Section, the Department may terminate, suspend, or exclude | 13 | | vendors who pose a risk of fraud, waste, abuse, or harm | 14 | | from
participation in the medical assistance program prior
| 15 | | to an evidentiary hearing but after reasonable notice and | 16 | | opportunity to
respond as established by the Department by | 17 | | rule.
| 18 | | (2) Vendors who pose a risk of fraud, waste, abuse, or | 19 | | harm shall submit to a fingerprint-based criminal
| 20 | | background check on current and future information | 21 | | available in the State
system and current information | 22 | | available through the Federal Bureau of
Investigation's | 23 | | system by submitting all necessary fees and information in | 24 | | the
form and manner
prescribed by the Department of State | 25 | | Police. The following individuals shall
be subject to the | 26 | | check:
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| 1 | | (A) In the case of a vendor that is a corporation, | 2 | | every shareholder
who owns, directly or indirectly, 5% | 3 | | or more of the outstanding shares of
the corporation.
| 4 | | (B) In the case of a vendor that is a partnership, | 5 | | every partner.
| 6 | | (C) In the case of a vendor that is a sole | 7 | | proprietorship, the sole
proprietor.
| 8 | | (D) Each officer or manager of the vendor.
| 9 | | Each such vendor shall be responsible for payment of | 10 | | the cost of the
criminal background check.
| 11 | | (3) Vendors who pose a risk of fraud, waste, abuse, or | 12 | | harm may be
required to post a surety bond. The Department | 13 | | shall establish, by rule, the
criteria and requirements for | 14 | | determining when a surety bond must be posted and
the value | 15 | | of the bond.
| 16 | | (4) The Department, or its agents, may refuse to accept | 17 | | requests for authorization from specific vendors who pose a | 18 | | risk of fraud, waste, abuse, or harm, including | 19 | | prior-approval and
post-approval requests, if:
| 20 | | (A) the Department has initiated a notice of | 21 | | termination, suspension, or exclusion of the
vendor | 22 | | from participation in the medical assistance program; | 23 | | or
| 24 | | (B) the Department has issued notification of its | 25 | | withholding of
payments pursuant to subsection (F-5) | 26 | | of this Section; or
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| 1 | | (C) the Department has issued a notification of its | 2 | | withholding of
payments due to reliable evidence of | 3 | | fraud or willful misrepresentation
pending | 4 | | investigation.
| 5 | | (5) As used in this subsection, the following terms are | 6 | | defined as follows: | 7 | | (A) "Fraud" means an intentional deception or | 8 | | misrepresentation made by a person with the knowledge | 9 | | that the deception could result in some unauthorized | 10 | | benefit to himself or herself or some other person. It | 11 | | includes any act that constitutes fraud under | 12 | | applicable federal or State law. | 13 | | (B) "Abuse" means provider practices that are | 14 | | inconsistent with sound fiscal, business, or medical | 15 | | practices and that result in an unnecessary cost to the | 16 | | medical assistance program or in reimbursement for | 17 | | services that are not medically necessary or that fail | 18 | | to meet professionally recognized standards for health | 19 | | care. It also includes recipient practices that result | 20 | | in unnecessary cost to the medical assistance program. | 21 | | Abuse does not include diagnostic or therapeutic | 22 | | measures conducted primarily as a safeguard against | 23 | | possible vendor liability. | 24 | | (C) "Waste" means the unintentional misuse of | 25 | | medical assistance resources, resulting in unnecessary | 26 | | cost to the medical assistance program. Waste does not |
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| 1 | | include diagnostic or therapeutic measures conducted | 2 | | primarily as a safeguard against possible vendor | 3 | | liability. | 4 | | (D) "Harm" means physical, mental, or monetary | 5 | | damage to recipients or to the medical assistance | 6 | | program. | 7 | | (G-6) The Illinois Department, upon making a determination | 8 | | based upon information in the possession of the Illinois | 9 | | Department that continuation of participation in the medical | 10 | | assistance program by a vendor would constitute an immediate | 11 | | danger to the public, may immediately suspend such vendor's | 12 | | participation in the medical assistance program without a | 13 | | hearing. In instances in which the Illinois Department | 14 | | immediately suspends the medical assistance program | 15 | | participation of a vendor under this Section, a hearing upon | 16 | | the vendor's participation must be convened by the Illinois | 17 | | Department within 15 days after such suspension and completed | 18 | | without appreciable delay. Such hearing shall be held to | 19 | | determine whether to recommend to the Director that the | 20 | | vendor's medical assistance program participation be denied, | 21 | | terminated, suspended, placed on provisional status, or | 22 | | reinstated. In the hearing, any evidence relevant to the vendor | 23 | | constituting an immediate danger to the public may be | 24 | | introduced against such vendor; provided, however, that the | 25 | | vendor, or his or her counsel, shall have the opportunity to | 26 | | discredit, impeach, and submit evidence rebutting such |
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| 1 | | evidence. | 2 | | (H) Nothing contained in this Code shall in any way limit | 3 | | or
otherwise impair the authority or power of any State agency | 4 | | responsible
for licensing of vendors.
| 5 | | (I) Based on a finding of noncompliance on the part of a | 6 | | nursing home with
any requirement for certification under Title | 7 | | XVIII or XIX of the Social
Security Act (42 U.S.C. Sec. 1395 et | 8 | | seq. or 42 U.S.C. Sec. 1396 et seq.), the
Illinois Department | 9 | | may impose one or more of the following remedies after
notice | 10 | | to the facility:
| 11 | | (1) Termination of the provider agreement.
| 12 | | (2) Temporary management.
| 13 | | (3) Denial of payment for new admissions.
| 14 | | (4) Civil money penalties.
| 15 | | (5) Closure of the facility in emergency situations or | 16 | | transfer of
residents, or both.
| 17 | | (6) State monitoring.
| 18 | | (7) Denial of all payments when the U.S. Department of | 19 | | Health and Human Services has
imposed this sanction.
| 20 | | The Illinois Department shall by rule establish criteria | 21 | | governing continued
payments to a nursing facility subsequent | 22 | | to termination of the facility's
provider agreement if, in the | 23 | | sole discretion of the Illinois Department,
circumstances | 24 | | affecting the health, safety, and welfare of the facility's
| 25 | | residents require those continued payments. The Illinois | 26 | | Department may
condition those continued payments on the |
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| 1 | | appointment of temporary management,
sale of the facility to | 2 | | new owners or operators, or other
arrangements that the | 3 | | Illinois Department determines best serve the needs of
the | 4 | | facility's residents.
| 5 | | Except in the case of a facility that has a right to a | 6 | | hearing on the finding
of noncompliance before an agency of the | 7 | | federal government, a facility may
request a hearing before a | 8 | | State agency on any finding of noncompliance within
60 days | 9 | | after the notice of the intent to impose a remedy. Except in | 10 | | the case
of civil money penalties, a request for a hearing | 11 | | shall not delay imposition of
the penalty. The choice of | 12 | | remedies is not appealable at a hearing. The level
of | 13 | | noncompliance may be challenged only in the case of a civil | 14 | | money penalty.
The Illinois Department shall provide by rule | 15 | | for the State agency that will
conduct the evidentiary | 16 | | hearings.
| 17 | | The Illinois Department may collect interest on unpaid | 18 | | civil money penalties.
| 19 | | The Illinois Department may adopt all rules necessary to | 20 | | implement this
subsection (I).
| 21 | | (J) The Illinois Department, by rule, may permit individual | 22 | | practitioners to designate that Department payments that may be | 23 | | due the practitioner be made to an alternate payee or alternate | 24 | | payees. | 25 | | (a) Such alternate payee or alternate payees shall be | 26 | | required to register as an alternate payee in the Medical |
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| 1 | | Assistance Program with the Illinois Department. | 2 | | (b) If a practitioner designates an alternate payee, | 3 | | the alternate payee and practitioner shall be jointly and | 4 | | severally liable to the Department for payments made to the | 5 | | alternate payee. Pursuant to subsection (E) of this | 6 | | Section, any Department action to suspend or deny payment | 7 | | or recover money or overpayments from an alternate payee | 8 | | shall be subject to an administrative hearing. | 9 | | (c) Registration as an alternate payee or alternate | 10 | | payees in the Illinois Medical Assistance Program shall be | 11 | | conditional. At any time, the Illinois Department may deny | 12 | | or cancel any alternate payee's registration in the | 13 | | Illinois Medical Assistance Program without cause. Any | 14 | | such denial or cancellation is not subject to an | 15 | | administrative hearing. | 16 | | (d) The Illinois Department may seek a revocation of | 17 | | any alternate payee, and all owners, officers, and | 18 | | individuals with management responsibility for such | 19 | | alternate payee shall be permanently prohibited from | 20 | | participating as an owner, an officer, or an individual | 21 | | with management responsibility with an alternate payee in | 22 | | the Illinois Medical Assistance Program, if after | 23 | | reasonable notice and opportunity for a hearing the | 24 | | Illinois Department finds that: | 25 | | (1) the alternate payee is not complying with the | 26 | | Department's policy or rules and regulations, or with |
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| 1 | | the terms and conditions prescribed by the Illinois | 2 | | Department in its alternate payee registration | 3 | | agreement; or | 4 | | (2) the alternate payee has failed to keep or make | 5 | | available for inspection, audit, or copying, after | 6 | | receiving a written request from the Illinois | 7 | | Department, such records regarding payments claimed as | 8 | | an alternate payee; or | 9 | | (3) the alternate payee has failed to furnish any | 10 | | information requested by the Illinois Department | 11 | | regarding payments claimed as an alternate payee; or | 12 | | (4) the alternate payee has knowingly made, or | 13 | | caused to be made, any false statement or | 14 | | representation of a material fact in connection with | 15 | | the administration of the Illinois Medical Assistance | 16 | | Program; or | 17 | | (5) the alternate payee, a person with management | 18 | | responsibility for an alternate payee, an officer or | 19 | | person owning, either directly or indirectly, 5% or | 20 | | more of the shares of stock or other evidences of | 21 | | ownership in a corporate alternate payee, or a partner | 22 | | in a partnership which is an alternate payee: | 23 | | (a) was previously terminated, suspended, or | 24 | | excluded from participation as a vendor in the | 25 | | Illinois Medical Assistance Program, or was | 26 | | previously revoked as an alternate payee in the |
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| 1 | | Illinois Medical Assistance Program, or was | 2 | | terminated, suspended, or excluded from | 3 | | participation as a vendor in a medical assistance | 4 | | program in another state that is of the same kind | 5 | | as the program of medical assistance provided | 6 | | under Article V of this Code; or | 7 | | (b) was a person with management | 8 | | responsibility for a vendor previously terminated, | 9 | | suspended, or excluded from participation as a | 10 | | vendor in the Illinois Medical Assistance Program, | 11 | | or was previously revoked as an alternate payee in | 12 | | the Illinois Medical Assistance Program, or was | 13 | | terminated, suspended, or excluded from | 14 | | participation as a vendor in a medical assistance | 15 | | program in another state that is of the same kind | 16 | | as the program of medical assistance provided | 17 | | under Article V of this Code, during the time of | 18 | | conduct which was the basis for that vendor's | 19 | | termination, suspension, or exclusion or alternate | 20 | | payee's revocation; or | 21 | | (c) was an officer, or person owning, either | 22 | | directly or indirectly, 5% or more of the shares of | 23 | | stock or other evidences of ownership in a | 24 | | corporate vendor previously terminated, suspended, | 25 | | or excluded from participation as a vendor in the | 26 | | Illinois Medical Assistance Program, or was |
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| 1 | | previously revoked as an alternate payee in the | 2 | | 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 | 10 | | (d) was an owner of a sole proprietorship or | 11 | | partner in a partnership previously terminated, | 12 | | suspended, or excluded from participation as a | 13 | | vendor in the Illinois Medical Assistance Program, | 14 | | or was previously revoked as an alternate payee in | 15 | | the Illinois Medical Assistance Program, or was | 16 | | terminated, suspended, or excluded from | 17 | | participation as a vendor in a medical assistance | 18 | | program in another state that is of the same kind | 19 | | as the program of medical assistance provided | 20 | | under Article V of this Code, during the time of | 21 | | conduct which was the basis for that vendor's | 22 | | termination, suspension, or exclusion or alternate | 23 | | payee's revocation; or | 24 | | (6) the alternate payee, a person with management | 25 | | responsibility for an alternate payee, an officer or | 26 | | person owning, either directly or indirectly, 5% or |
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| 1 | | more of the shares of stock or other evidences of | 2 | | ownership in a corporate alternate payee, or a partner | 3 | | in a partnership which is an alternate payee: | 4 | | (a) has engaged in conduct prohibited by | 5 | | applicable federal or State law or regulation | 6 | | relating to the Illinois Medical Assistance | 7 | | Program; or | 8 | | (b) was a person with management | 9 | | responsibility for a vendor or alternate payee at | 10 | | the time that the vendor or alternate payee engaged | 11 | | in practices prohibited by applicable federal or | 12 | | State law or regulation relating to the Illinois | 13 | | Medical Assistance Program; or | 14 | | (c) was an officer, or person owning, either | 15 | | directly or indirectly, 5% or more of the shares of | 16 | | stock or other evidences of ownership in a vendor | 17 | | or alternate payee at the time such vendor or | 18 | | alternate payee engaged in practices prohibited by | 19 | | applicable federal or State law or regulation | 20 | | relating to the Illinois Medical Assistance | 21 | | Program; or | 22 | | (d) was an owner of a sole proprietorship or | 23 | | partner in a partnership which was a vendor or | 24 | | alternate payee at the time such vendor or | 25 | | alternate payee engaged in practices prohibited by | 26 | | applicable federal or State law or regulation |
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| 1 | | relating to the Illinois Medical Assistance | 2 | | Program; or | 3 | | (7) the direct or indirect ownership of the vendor | 4 | | or alternate payee (including the ownership of a vendor | 5 | | or alternate payee that is a partner's interest in a | 6 | | vendor or alternate payee, or ownership of 5% or more | 7 | | of the shares of stock or other evidences of ownership | 8 | | in a corporate vendor or alternate payee) has been | 9 | | transferred by an individual who is terminated, | 10 | | suspended, or excluded or barred from participating as | 11 | | a vendor or is prohibited or revoked as an alternate | 12 | | payee to the individual's spouse, child, brother, | 13 | | sister, parent, grandparent, grandchild, uncle, aunt, | 14 | | niece, nephew, cousin, or relative by marriage. | 15 | | (K) The Illinois Department of Healthcare and Family | 16 | | Services may withhold payments, in whole or in part, to a | 17 | | provider or alternate payee where there is credible evidence, | 18 | | received from State or federal law enforcement or federal | 19 | | oversight agencies or from the results of a preliminary | 20 | | Department audit, that the circumstances giving rise to the | 21 | | need for a withholding of payments may involve fraud or willful | 22 | | misrepresentation under the Illinois Medical Assistance | 23 | | program. The Department shall by rule define what constitutes | 24 | | "credible" evidence for purposes of this subsection. The | 25 | | Department may withhold payments without first notifying the | 26 | | provider or alternate payee of its intention to withhold such |
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| 1 | | payments. A provider or alternate payee may request a | 2 | | reconsideration of payment withholding, and the Department | 3 | | must grant such a request. The Department shall state by rule a | 4 | | process and criteria by which a provider or alternate payee may | 5 | | request full or partial release of payments withheld under this | 6 | | subsection. This request may be made at any time after the | 7 | | Department first withholds such payments. | 8 | | (a) The Illinois Department must send notice of its
| 9 | | withholding of program payments within 5 days of taking | 10 | | such action. The notice must set forth the general | 11 | | allegations as to the nature of the withholding action, but | 12 | | need not disclose any specific information concerning its | 13 | | ongoing investigation. The notice must do all of the | 14 | | following: | 15 | | (1) State that payments are being withheld in
| 16 | | accordance with this subsection. | 17 | | (2) State that the withholding is for a temporary
| 18 | | period, as stated in paragraph (b) of this
subsection, | 19 | | and cite the circumstances under which
withholding | 20 | | will be terminated. | 21 | | (3) Specify, when appropriate, which type or types
| 22 | | of Medicaid claims withholding is effective. | 23 | | (4) Inform the provider or alternate payee of the
| 24 | | right to submit written evidence for reconsideration | 25 | | of the withholding by
the Illinois Department. | 26 | | (5) Inform the provider or alternate payee that a |
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| 1 | | written request may be made to the Illinois Department | 2 | | for full or partial release of withheld payments and | 3 | | that such requests may be made at any time after the | 4 | | Department first withholds such payments.
| 5 | | (b) All withholding-of-payment actions under this
| 6 | | subsection shall be temporary and shall not continue after | 7 | | any of the following: | 8 | | (1) The Illinois Department or the prosecuting
| 9 | | authorities determine that there is insufficient
| 10 | | evidence of fraud or willful misrepresentation by the
| 11 | | provider or alternate payee. | 12 | | (2) Legal proceedings related to the provider's or
| 13 | | alternate payee's alleged fraud, willful
| 14 | | misrepresentation, violations of this Act, or
| 15 | | violations of the Illinois Department's administrative
| 16 | | rules are completed. | 17 | | (3) The withholding of payments for a period of 3 | 18 | | years.
| 19 | | (c) The Illinois Department may adopt all rules | 20 | | necessary
to implement this subsection (K).
| 21 | | (K-5) The Illinois Department may withhold payments, in | 22 | | whole or in part, to a provider or alternate payee upon | 23 | | initiation of an audit, quality of care review, investigation | 24 | | when there is a credible allegation of fraud, or the provider | 25 | | or alternate payee demonstrating a clear failure to cooperate | 26 | | with the Illinois Department such that the circumstances give |
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| 1 | | rise to the need for a withholding of payments. As used in this | 2 | | subsection, "credible allegation" is defined to include an | 3 | | allegation from any source, including, but not limited to, | 4 | | fraud hotline complaints, claims data mining, patterns | 5 | | identified through provider audits, civil actions filed under | 6 | | the Illinois False Claims Act, and law enforcement | 7 | | investigations. An allegation is considered to be credible when | 8 | | it has indicia of reliability. The Illinois Department may | 9 | | withhold payments without first notifying the provider or | 10 | | alternate payee of its intention to withhold such payments. A | 11 | | provider or alternate payee may request a hearing or a | 12 | | reconsideration of payment withholding, and the Illinois | 13 | | Department must grant such a request. The Illinois Department | 14 | | shall state by rule a process and criteria by which a provider | 15 | | or alternate payee may request a hearing or a reconsideration | 16 | | for the full or partial release of payments withheld under this | 17 | | subsection. This request may be made at any time after the | 18 | | Illinois Department first withholds such payments. | 19 | | (a) The Illinois Department must send notice of its | 20 | | withholding of program payments within 5 days of taking | 21 | | such action. The notice must set forth the general | 22 | | allegations as to the nature of the withholding action but | 23 | | need not disclose any specific information concerning its | 24 | | ongoing investigation. The notice must do all of the | 25 | | following: | 26 | | (1) State that payments are being withheld in |
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| 1 | | accordance with this subsection. | 2 | | (2) State that the withholding is for a temporary | 3 | | period, as stated in paragraph (b) of this subsection, | 4 | | and cite the circumstances under which withholding | 5 | | will be terminated. | 6 | | (3) Specify, when appropriate, which type or types | 7 | | of claims are withheld. | 8 | | (4) Inform the provider or alternate payee of the | 9 | | right to request a hearing or a reconsideration of the | 10 | | withholding by the Illinois Department, including the | 11 | | ability to submit written evidence. | 12 | | (5) Inform the provider or alternate payee that a | 13 | | written request may be made to the Illinois Department | 14 | | for a hearing or a reconsideration for the full or | 15 | | partial release of withheld payments and that such | 16 | | requests may be made at any time after the Illinois | 17 | | Department first withholds such payments. | 18 | | (b) All withholding of payment actions under this | 19 | | subsection shall be temporary and shall not continue after | 20 | | any of the following: | 21 | | (1) The Illinois Department determines that there | 22 | | is insufficient evidence of fraud, or the provider or | 23 | | alternate payee demonstrates clear cooperation with | 24 | | the Illinois Department, as determined by the Illinois | 25 | | Department, such that the circumstances do not give | 26 | | rise to the need for withholding of payments; or |
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| 1 | | (2) The withholding of payments has lasted for a | 2 | | period in excess of 3 years. | 3 | | (c) The Illinois Department may adopt all rules | 4 | | necessary to implement this subsection (K-5). | 5 | | (L) The Illinois Department shall establish a protocol to | 6 | | enable health care providers to disclose an actual or potential | 7 | | violation of this Section pursuant to a self-referral | 8 | | disclosure protocol, referred to in this subsection as "the | 9 | | protocol". The protocol shall include direction for health care | 10 | | providers on a specific person, official, or office to whom | 11 | | such disclosures shall be made. The Illinois Department shall | 12 | | post information on the protocol on the Illinois Department's | 13 | | public website. The Illinois Department may adopt rules | 14 | | necessary to implement this subsection (L). In addition to | 15 | | other factors that the Illinois Department finds appropriate, | 16 | | the Illinois Department may consider a health care provider's | 17 | | timely use or failure to use the protocol in considering the | 18 | | provider's failure to comply with this Code. | 19 | | (M) Notwithstanding any other provision of this Code, the | 20 | | Illinois Department, at its discretion, may exempt an entity | 21 | | licensed under the Nursing Home Care Act and the ID/DD | 22 | | Community Care Act from the provisions of subsections (A-15), | 23 | | (B), and (C) of this Section if the licensed entity is in | 24 | | receivership. | 25 | | (Source: P.A. 97-689, eff. 6-14-12; 97-1150, eff. 1-25-13.)
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| 1 | | Section 99. Effective date. This Act takes effect upon | 2 | | becoming law.".
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