Full Text of HB3537 100th General Assembly
HB3537ham001 100TH GENERAL ASSEMBLY | Rep. Natalie A. Manley Filed: 3/15/2017
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| 1 | | AMENDMENT TO HOUSE BILL 3537
| 2 | | AMENDMENT NO. ______. Amend House Bill 3537 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 12-13.1 as follows:
| 6 | | (305 ILCS 5/12-13.1)
| 7 | | Sec. 12-13.1. Inspector General.
| 8 | | (a) The Governor shall appoint, and the Senate shall | 9 | | confirm, an Inspector
General who shall function within the | 10 | | Illinois Department of Public Aid (now Healthcare and Family | 11 | | Services) and
report to the Governor. The term of the Inspector | 12 | | General shall expire on the
third Monday of January, 1997 and | 13 | | every 4 years thereafter.
| 14 | | (b) In order to prevent, detect, and eliminate fraud, | 15 | | waste, abuse,
mismanagement, and misconduct, the Inspector | 16 | | General shall oversee the
Department of Healthcare and Family |
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| 1 | | Services' and the Department on Aging's integrity
functions, | 2 | | which include, but are not limited to, the following:
| 3 | | (1) Investigation of misconduct by employees, vendors, | 4 | | contractors and
medical providers, except for allegations | 5 | | of violations of the State Officials and Employees Ethics | 6 | | Act which shall be referred to the Office of the Governor's | 7 | | Executive Inspector General for investigation.
| 8 | | (2) Prepayment and post-payment audits of medical | 9 | | providers related to ensuring that appropriate
payments | 10 | | are made for services rendered and to the prevention and | 11 | | recovery of overpayments.
| 12 | | (3) Monitoring of quality assurance programs | 13 | | administered by the Department of Healthcare and Family
| 14 | | Services and the Community Care Program administered by the | 15 | | Department on Aging.
| 16 | | (4) Quality control measurements of the programs | 17 | | administered by the
Department of Healthcare and Family | 18 | | Services and the Community Care Program administered by the | 19 | | Department on Aging.
| 20 | | (5) Investigations of fraud or intentional program | 21 | | violations committed by
clients of the Department of | 22 | | Healthcare and Family Services and the Community Care | 23 | | Program administered by the Department on Aging.
| 24 | | (6) Actions initiated against contractors, vendors, or | 25 | | medical providers for any of
the following reasons:
| 26 | | (A) Violations of the medical assistance program |
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| 1 | | and the Community Care Program administered by the | 2 | | Department on Aging.
| 3 | | (B) Sanctions against providers brought in | 4 | | conjunction with the
Department of Public Health or the | 5 | | Department of Human Services (as successor
to the | 6 | | Department of Mental Health and Developmental | 7 | | Disabilities).
| 8 | | (C) Recoveries of assessments against hospitals | 9 | | and long-term care
facilities.
| 10 | | (D) Sanctions mandated by the United States | 11 | | Department of Health and
Human Services against | 12 | | medical providers.
| 13 | | (E) Violations of contracts related to any | 14 | | programs administered by the Department of Healthcare
| 15 | | and Family Services and the Community Care Program | 16 | | administered by the Department on Aging.
| 17 | | (7) Representation of the Department of Healthcare and | 18 | | Family Services at
hearings with the Illinois Department of | 19 | | Financial and Professional Regulation in actions
taken | 20 | | against professional licenses held by persons who are in | 21 | | violation of
orders for child support payments.
| 22 | | (b-5) At the request of the Secretary of Human Services, | 23 | | the Inspector
General shall, in relation to any function | 24 | | performed by the Department of Human
Services as successor to | 25 | | the Department of Public Aid, exercise one or more
of the | 26 | | powers provided under this Section as if those powers related |
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| 1 | | to the
Department of Human Services; in such matters, the | 2 | | Inspector General shall
report his or her findings to the | 3 | | Secretary of Human Services.
| 4 | | (c) Notwithstanding, and in addition to, any other
| 5 | | provision of law, the Inspector General shall have access to | 6 | | all information, personnel
and facilities of the
Department of | 7 | | Healthcare and Family Services and the Department of
Human | 8 | | Services (as successor to the Department of Public Aid), their | 9 | | employees, vendors, contractors and medical providers and any | 10 | | federal,
State or local governmental agency that are necessary | 11 | | to perform the duties of
the Office as directly related to | 12 | | public assistance programs administered by
those departments. | 13 | | No medical provider shall
be compelled, however, to provide | 14 | | individual medical records of patients who
are not clients of | 15 | | the programs administered by the Department of Healthcare and
| 16 | | Family Services. State and local
governmental agencies are | 17 | | authorized and directed to provide the requested
information, | 18 | | assistance or cooperation.
| 19 | | For purposes of enhanced program integrity functions and
| 20 | | oversight, and to the extent consistent with applicable
| 21 | | information and privacy, security, and disclosure laws, State
| 22 | | agencies and departments shall provide the Office of Inspector | 23 | | General access to confidential and other information and data, | 24 | | and the Inspector General is authorized to enter into | 25 | | agreements with appropriate federal agencies and departments | 26 | | to secure similar data. This includes, but is not limited to, |
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| 1 | | information pertaining to: licensure; certification; earnings; | 2 | | immigration status; citizenship; wage reporting; unearned and | 3 | | earned income; pension income;
employment; supplemental | 4 | | security income; social security
numbers; National Provider | 5 | | Identifier (NPI) numbers; the
National Practitioner Data Bank | 6 | | (NPDB); program and agency
exclusions; taxpayer identification | 7 | | numbers; tax delinquency;
corporate information; and death | 8 | | records. | 9 | | The Inspector General shall enter into agreements with | 10 | | State agencies and departments, and is authorized to enter into | 11 | | agreements with federal agencies and departments, under which | 12 | | such agencies and departments shall share data necessary for | 13 | | medical assistance program integrity functions and oversight. | 14 | | The Inspector General shall enter into agreements with State | 15 | | agencies and departments, and is authorized to enter into | 16 | | agreements with federal agencies and departments, under which | 17 | | such agencies shall share data necessary for recipient and | 18 | | vendor screening, review, and investigation, including but not | 19 | | limited to vendor payment and recipient eligibility | 20 | | verification. The Inspector General shall develop, in | 21 | | cooperation with other State and federal agencies and | 22 | | departments, and in compliance with applicable federal laws and | 23 | | regulations, appropriate and effective
methods to share such | 24 | | data. The Inspector General shall enter into agreements with | 25 | | State agencies and departments, and is authorized to enter into | 26 | | agreements with federal agencies and departments, including, |
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| 1 | | but not limited to: the Secretary of State; the
Department of | 2 | | Revenue; the Department of Public Health; the
Department of | 3 | | Human Services; and the Department of Financial and | 4 | | Professional Regulation. | 5 | | The Inspector General shall have the authority to deny | 6 | | payment, prevent overpayments, and recover overpayments. | 7 | | The Inspector General shall have the authority to deny or
| 8 | | suspend payment to, and deny, terminate, or suspend the
| 9 | | eligibility of, any vendor who fails to grant the Inspector
| 10 | | General timely access to full and complete records, including | 11 | | records of recipients under the medical assistance program for | 12 | | the most recent 6 years, in accordance with Section 140.28 of | 13 | | Title 89 of the Illinois Administrative Code, and other | 14 | | information for the purpose of audits, investigations, or other | 15 | | program integrity functions, after reasonable written request | 16 | | by the Inspector General. | 17 | | (c-5) The Inspector General must perform all audits with as | 18 | | much transparency as possible and maintain due process | 19 | | throughout the audit process and any and all appeals of the | 20 | | audit process. The Inspector General must provide a clear, | 21 | | well-supported case in all audits. The Inspector General must | 22 | | also clearly inform providers of their rights in appealing all | 23 | | findings. The Inspector General shall, at a minimum, do the | 24 | | following: | 25 | | (1) Inform a provider, at the time of notification of | 26 | | an audit, of any and all laws, regulations, administrative |
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| 1 | | rules, policies, and procedures which are tested and | 2 | | reviewed as part of the audit. | 3 | | (2) Identify and present in all final audit reports all | 4 | | documentation supporting any findings that are sufficient | 5 | | to allow a provider to clearly follow the decision making | 6 | | process. The audit report must also include a sufficient | 7 | | and clear narrative explaining how the documentation | 8 | | presented supports the audit findings and the reasons for | 9 | | disregarding any other documentary evidence to the | 10 | | contrary. The narrative must clearly cite the relevant | 11 | | legal authority applied in the finding. | 12 | | (3) Prior to issuing a final audit report, honor a | 13 | | request by a provider for a review by another auditor | 14 | | different than the one issuing the findings. | 15 | | (4) Clearly delineate in all final audit reports: (i) | 16 | | the entire appeal process and (ii) the rights of the | 17 | | provider as opposed to referencing administrative rules or | 18 | | other legal authority. The final audit report must | 19 | | specifically state any date deadlines and provide contact | 20 | | information in case there are questions about the appeal. | 21 | | (5) Allow a provider the option of having any and all | 22 | | hearings in Springfield. The Inspector General may not | 23 | | require holding any and all hearings in Chicago. The | 24 | | location of hearings must not be used as an obstacle to | 25 | | allowing a provider to exercise its rights to appeal. | 26 | | (d) The Inspector General shall serve as the
Department of |
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| 1 | | Healthcare and Family Services'
primary liaison with law | 2 | | enforcement,
investigatory and prosecutorial agencies, | 3 | | including but not limited to the
following:
| 4 | | (1) The Department of State Police.
| 5 | | (2) The Federal Bureau of Investigation and other | 6 | | federal law enforcement
agencies.
| 7 | | (3) The various Inspectors General of federal agencies | 8 | | overseeing the
programs administered by the
Department of | 9 | | Healthcare and Family Services.
| 10 | | (4) The various Inspectors General of any other State | 11 | | agencies with
responsibilities for portions of programs | 12 | | primarily administered by the
Department of Healthcare and | 13 | | Family Services.
| 14 | | (5) The Offices of the several United States Attorneys | 15 | | in Illinois.
| 16 | | (6) The several State's Attorneys.
| 17 | | (7) The offices of the Centers for Medicare and | 18 | | Medicaid Services that administer the Medicare and | 19 | | Medicaid integrity programs. | 20 | | The Inspector General shall meet on a regular basis with | 21 | | these entities to
share information regarding possible | 22 | | misconduct by any persons or entities
involved with the public | 23 | | aid programs administered by the Department
of Healthcare and | 24 | | Family Services.
| 25 | | (e) All investigations conducted by the Inspector General | 26 | | shall be conducted
in a manner that ensures the preservation of |
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| 1 | | evidence for use in criminal
prosecutions. If the Inspector | 2 | | General determines that a possible criminal act
relating to | 3 | | fraud in the provision or administration of the medical | 4 | | assistance
program has been committed, the Inspector General | 5 | | shall immediately notify the
Medicaid Fraud Control Unit. If | 6 | | the Inspector General determines that a
possible criminal act | 7 | | has been committed within the jurisdiction of the Office,
the | 8 | | Inspector General may request the special expertise of the | 9 | | Department of
State Police. The Inspector General may present | 10 | | for prosecution the findings
of any criminal investigation to | 11 | | the Office of the Attorney General, the
Offices of the several | 12 | | United States Attorneys in Illinois or the several
State's | 13 | | Attorneys.
| 14 | | (f) To carry out his or her duties as described in this | 15 | | Section, the
Inspector General and his or her designees shall | 16 | | have the power to compel
by subpoena the attendance and | 17 | | testimony of witnesses and the production
of books, electronic | 18 | | records and papers as directly related to public
assistance | 19 | | programs administered by the Department of Healthcare and | 20 | | Family Services or
the Department of Human Services (as | 21 | | successor to the Department of Public
Aid). No medical provider | 22 | | shall be compelled, however, to provide individual
medical | 23 | | records of patients who are not clients of the Medical | 24 | | Assistance
Program.
| 25 | | (g) The Inspector General shall report all convictions, | 26 | | terminations, and
suspensions taken against vendors, |
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| 1 | | contractors and medical providers to the
Department of | 2 | | Healthcare and Family Services and to any agency responsible | 3 | | for
licensing or regulating those persons or entities.
| 4 | | (h) The Inspector General shall make annual
reports, | 5 | | findings, and recommendations regarding the Office's | 6 | | investigations
into reports of fraud, waste, abuse, | 7 | | mismanagement, or misconduct relating to
any programs | 8 | | administered by the Department
of Healthcare and Family | 9 | | Services or the Department of Human Services (as successor to | 10 | | the
Department of Public Aid) to the General Assembly and the | 11 | | Governor. These
reports shall include, but not be limited to, | 12 | | the following information:
| 13 | | (1) Aggregate provider billing and payment | 14 | | information, including the
number of providers at various | 15 | | Medicaid earning levels.
| 16 | | (2) The number of audits of the medical assistance
| 17 | | program and the dollar savings resulting from those audits.
| 18 | | (3) The number of prescriptions rejected annually | 19 | | under the
Department of Healthcare and Family Services' | 20 | | Refill Too Soon program and the
dollar savings resulting | 21 | | from that program.
| 22 | | (4) Provider sanctions, in the aggregate, including | 23 | | terminations and
suspensions.
| 24 | | (5) A detailed summary of the investigations | 25 | | undertaken in the previous
fiscal year. These summaries | 26 | | shall comply with all laws and rules regarding
maintaining |
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| 1 | | confidentiality in the public aid programs.
| 2 | | (i) Nothing in this Section shall limit investigations by | 3 | | the
Department of Healthcare and Family Services or the | 4 | | Department of Human Services that may
otherwise be required by | 5 | | law or that may be necessary in their capacity as the
central | 6 | | administrative authorities responsible for administration of | 7 | | their agency's
programs in this
State.
| 8 | | (j) The Inspector General may issue shields or other | 9 | | distinctive identification to his or her employees not | 10 | | exercising the powers of a peace officer if the Inspector | 11 | | General determines that a shield or distinctive identification | 12 | | is needed by an employee to carry out his or her | 13 | | responsibilities. | 14 | | (Source: P.A. 97-689, eff. 6-14-12; 98-8, eff. 5-3-13.)".
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