Senate Bill sb1064
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Florida Senate - 2004 SB 1064
By Senator Saunders
37-769-04
1 A bill to be entitled
2 An act relating to Medicaid; amending s.
3 409.912, F.S.; authorizing the Agency for
4 Health Care Administration to impose mandatory
5 enrollment in drug-therapy-management or
6 disease-management programs for certain
7 categories of recipients; amending s. 409.913,
8 F.S.; providing specified conditions for
9 providers to meet in order to submit claims to
10 the Medicaid program; providing that claims may
11 be denied if not properly submitted; providing
12 that the agency may seek any remedy under law
13 if a provider submits specified false or
14 erroneous claims; providing that suspension or
15 termination precludes participation in the
16 Medicaid program; providing that the agency is
17 required to report administrative sanctions to
18 licensing authorities for certain violations;
19 providing that the agency may withhold payment
20 to a provider under certain circumstances;
21 providing that the agency may deny payments to
22 terminated or suspended providers; authorizing
23 the agency to implement amnesty projects for
24 providers to voluntarily repay overpayments;
25 authorizing the agency to adopt rules;
26 providing for limiting, restricting, or
27 suspending Medicaid eligibility of Medicaid
28 recipients convicted of certain crimes or
29 offenses; amending s. 409.9131, F.S.;
30 redefining the term "peer review"; providing
31 for peer review for purposes of determining a
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1 potential overpayment if the medical necessity
2 or quality of care is evaluated; providing an
3 effective date.
4
5 Be It Enacted by the Legislature of the State of Florida:
6
7 Section 1. Paragraph (a) of subsection (40) of section
8 409.912, Florida Statutes, is amended to read:
9 409.912 Cost-effective purchasing of health care.--The
10 agency shall purchase goods and services for Medicaid
11 recipients in the most cost-effective manner consistent with
12 the delivery of quality medical care. The agency shall
13 maximize the use of prepaid per capita and prepaid aggregate
14 fixed-sum basis services when appropriate and other
15 alternative service delivery and reimbursement methodologies,
16 including competitive bidding pursuant to s. 287.057, designed
17 to facilitate the cost-effective purchase of a case-managed
18 continuum of care. The agency shall also require providers to
19 minimize the exposure of recipients to the need for acute
20 inpatient, custodial, and other institutional care and the
21 inappropriate or unnecessary use of high-cost services. The
22 agency may establish prior authorization requirements for
23 certain populations of Medicaid beneficiaries, certain drug
24 classes, or particular drugs to prevent fraud, abuse, overuse,
25 and possible dangerous drug interactions. The Pharmaceutical
26 and Therapeutics Committee shall make recommendations to the
27 agency on drugs for which prior authorization is required. The
28 agency shall inform the Pharmaceutical and Therapeutics
29 Committee of its decisions regarding drugs subject to prior
30 authorization.
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1 (40)(a) The agency shall implement a Medicaid
2 prescribed-drug spending-control program that includes the
3 following components:
4 1. Medicaid prescribed-drug coverage for brand-name
5 drugs for adult Medicaid recipients is limited to the
6 dispensing of four brand-name drugs per month per recipient.
7 Children are exempt from this restriction. Antiretroviral
8 agents are excluded from this limitation. No requirements for
9 prior authorization or other restrictions on medications used
10 to treat mental illnesses such as schizophrenia, severe
11 depression, or bipolar disorder may be imposed on Medicaid
12 recipients. Medications that will be available without
13 restriction for persons with mental illnesses include atypical
14 antipsychotic medications, conventional antipsychotic
15 medications, selective serotonin reuptake inhibitors, and
16 other medications used for the treatment of serious mental
17 illnesses. The agency shall also limit the amount of a
18 prescribed drug dispensed to no more than a 34-day supply. The
19 agency shall continue to provide unlimited generic drugs,
20 contraceptive drugs and items, and diabetic supplies. Although
21 a drug may be included on the preferred drug formulary, it
22 would not be exempt from the four-brand limit. The agency may
23 authorize exceptions to the brand-name-drug restriction based
24 upon the treatment needs of the patients, only when such
25 exceptions are based on prior consultation provided by the
26 agency or an agency contractor, but the agency must establish
27 procedures to ensure that:
28 a. There will be a response to a request for prior
29 consultation by telephone or other telecommunication device
30 within 24 hours after receipt of a request for prior
31 consultation;
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1 b. A 72-hour supply of the drug prescribed will be
2 provided in an emergency or when the agency does not provide a
3 response within 24 hours as required by sub-subparagraph a.;
4 and
5 c. Except for the exception for nursing home residents
6 and other institutionalized adults and except for drugs on the
7 restricted formulary for which prior authorization may be
8 sought by an institutional or community pharmacy, prior
9 authorization for an exception to the brand-name-drug
10 restriction is sought by the prescriber and not by the
11 pharmacy. When prior authorization is granted for a patient in
12 an institutional setting beyond the brand-name-drug
13 restriction, such approval is authorized for 12 months and
14 monthly prior authorization is not required for that patient.
15 2. Reimbursement to pharmacies for Medicaid prescribed
16 drugs shall be set at the average wholesale price less 13.25
17 percent.
18 3. The agency shall develop and implement a process
19 for managing the drug therapies of Medicaid recipients who are
20 using significant numbers of prescribed drugs each month. The
21 management process may include, but is not limited to,
22 comprehensive, physician-directed medical-record reviews,
23 claims analyses, and case evaluations to determine the medical
24 necessity and appropriateness of a patient's treatment plan
25 and drug therapies. The agency may contract with a private
26 organization to provide drug-program-management services. The
27 Medicaid drug benefit management program shall include
28 initiatives to manage drug therapies for HIV/AIDS patients,
29 patients using 20 or more unique prescriptions in a 180-day
30 period, and the top 1,000 patients in annual spending. The
31 agency may mandate enrollment in a drug-therapy-management or
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1 disease-management program for patients who are identified as
2 overusing or abusing services or medicines.
3 4. The agency may limit the size of its pharmacy
4 network based on need, competitive bidding, price
5 negotiations, credentialing, or similar criteria. The agency
6 shall give special consideration to rural areas in determining
7 the size and location of pharmacies included in the Medicaid
8 pharmacy network. A pharmacy credentialing process may include
9 criteria such as a pharmacy's full-service status, location,
10 size, patient educational programs, patient consultation,
11 disease-management services, and other characteristics. The
12 agency may impose a moratorium on Medicaid pharmacy enrollment
13 when it is determined that it has a sufficient number of
14 Medicaid-participating providers.
15 5. The agency shall develop and implement a program
16 that requires Medicaid practitioners who prescribe drugs to
17 use a counterfeit-proof prescription pad for Medicaid
18 prescriptions. The agency shall require the use of
19 standardized counterfeit-proof prescription pads by
20 Medicaid-participating prescribers or prescribers who write
21 prescriptions for Medicaid recipients. The agency may
22 implement the program in targeted geographic areas or
23 statewide.
24 6. The agency may enter into arrangements that require
25 manufacturers of generic drugs prescribed to Medicaid
26 recipients to provide rebates of at least 15.1 percent of the
27 average manufacturer price for the manufacturer's generic
28 products. These arrangements shall require that if a
29 generic-drug manufacturer pays federal rebates for
30 Medicaid-reimbursed drugs at a level below 15.1 percent, the
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1 manufacturer must provide a supplemental rebate to the state
2 in an amount necessary to achieve a 15.1-percent rebate level.
3 7. The agency may establish a preferred drug formulary
4 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
5 establishment of such formulary, it is authorized to negotiate
6 supplemental rebates from manufacturers that are in addition
7 to those required by Title XIX of the Social Security Act and
8 at no less than 10 percent of the average manufacturer price
9 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
10 unless the federal or supplemental rebate, or both, equals or
11 exceeds 25 percent. There is no upper limit on the
12 supplemental rebates the agency may negotiate. The agency may
13 determine that specific products, brand-name or generic, are
14 competitive at lower rebate percentages. Agreement to pay the
15 minimum supplemental rebate percentage will guarantee a
16 manufacturer that the Medicaid Pharmaceutical and Therapeutics
17 Committee will consider a product for inclusion on the
18 preferred drug formulary. However, a pharmaceutical
19 manufacturer is not guaranteed placement on the formulary by
20 simply paying the minimum supplemental rebate. Agency
21 decisions will be made on the clinical efficacy of a drug and
22 recommendations of the Medicaid Pharmaceutical and
23 Therapeutics Committee, as well as the price of competing
24 products minus federal and state rebates. The agency is
25 authorized to contract with an outside agency or contractor to
26 conduct negotiations for supplemental rebates. For the
27 purposes of this section, the term "supplemental rebates" may
28 include, at the agency's discretion, cash rebates and other
29 program benefits that offset a Medicaid expenditure. Such
30 other program benefits may include, but are not limited to,
31 disease management programs, drug product donation programs,
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1 drug utilization control programs, prescriber and beneficiary
2 counseling and education, fraud and abuse initiatives, and
3 other services or administrative investments with guaranteed
4 savings to the Medicaid program in the same year the rebate
5 reduction is included in the General Appropriations Act. The
6 agency is authorized to seek any federal waivers to implement
7 this initiative.
8 8. The agency shall establish an advisory committee
9 for the purposes of studying the feasibility of using a
10 restricted drug formulary for nursing home residents and other
11 institutionalized adults. The committee shall be comprised of
12 seven members appointed by the Secretary of Health Care
13 Administration. The committee members shall include two
14 physicians licensed under chapter 458 or chapter 459; three
15 pharmacists licensed under chapter 465 and appointed from a
16 list of recommendations provided by the Florida Long-Term Care
17 Pharmacy Alliance; and two pharmacists licensed under chapter
18 465.
19 9. The Agency for Health Care Administration shall
20 expand home delivery of pharmacy products. To assist Medicaid
21 patients in securing their prescriptions and reduce program
22 costs, the agency shall expand its current mail-order-pharmacy
23 diabetes-supply program to include all generic and brand-name
24 drugs used by Medicaid patients with diabetes. Medicaid
25 recipients in the current program may obtain nondiabetes drugs
26 on a voluntary basis. This initiative is limited to the
27 geographic area covered by the current contract. The agency
28 may seek and implement any federal waivers necessary to
29 implement this subparagraph.
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1 Section 2. Subsections (7), (10), (14), (15), (23),
2 and (24) of section 409.913, Florida Statutes, are amended,
3 and subsection (32) is added to that section, to read:
4 409.913 Oversight of the integrity of the Medicaid
5 program.--The agency shall operate a program to oversee the
6 activities of Florida Medicaid recipients, and providers and
7 their representatives, to ensure that fraudulent and abusive
8 behavior and neglect of recipients occur to the minimum extent
9 possible, and to recover overpayments and impose sanctions as
10 appropriate. Beginning January 1, 2003, and each year
11 thereafter, the agency and the Medicaid Fraud Control Unit of
12 the Department of Legal Affairs shall submit a joint report to
13 the Legislature documenting the effectiveness of the state's
14 efforts to control Medicaid fraud and abuse and to recover
15 Medicaid overpayments during the previous fiscal year. The
16 report must describe the number of cases opened and
17 investigated each year; the sources of the cases opened; the
18 disposition of the cases closed each year; the amount of
19 overpayments alleged in preliminary and final audit letters;
20 the number and amount of fines or penalties imposed; any
21 reductions in overpayment amounts negotiated in settlement
22 agreements or by other means; the amount of final agency
23 determinations of overpayments; the amount deducted from
24 federal claiming as a result of overpayments; the amount of
25 overpayments recovered each year; the amount of cost of
26 investigation recovered each year; the average length of time
27 to collect from the time the case was opened until the
28 overpayment is paid in full; the amount determined as
29 uncollectible and the portion of the uncollectible amount
30 subsequently reclaimed from the Federal Government; the number
31 of providers, by type, that are terminated from participation
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1 in the Medicaid program as a result of fraud and abuse; and
2 all costs associated with discovering and prosecuting cases of
3 Medicaid overpayments and making recoveries in such cases. The
4 report must also document actions taken to prevent
5 overpayments and the number of providers prevented from
6 enrolling in or reenrolling in the Medicaid program as a
7 result of documented Medicaid fraud and abuse and must
8 recommend changes necessary to prevent or recover
9 overpayments. For the 2001-2002 fiscal year, the agency shall
10 prepare a report that contains as much of this information as
11 is available to it.
12 (7) When presenting a claim for payment under the
13 Medicaid program, a provider has an affirmative duty to
14 supervise the provision of, and be responsible for, goods and
15 services claimed to have been provided, to supervise and be
16 responsible for preparation and submission of the claim, and
17 to present a claim that is true and accurate and that is for
18 goods and services that:
19 (a) Have actually been furnished to the recipient by
20 the provider prior to submitting the claim.
21 (b) Are Medicaid-covered goods or services that are
22 medically necessary.
23 (c) Are of a quality comparable to those furnished to
24 the general public by the provider's peers.
25 (d) Have not been billed in whole or in part to a
26 recipient or a recipient's responsible party, except for such
27 copayments, coinsurance, or deductibles that as are authorized
28 by the agency.
29 (e) Are provided in accord with applicable provisions
30 of all Medicaid rules, regulations, handbooks, and policies
31 and in accordance with federal, state, and local law.
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1 (f) Are documented by records made at the time the
2 goods or services were provided, demonstrating the medical
3 necessity for the goods or services rendered. Medicaid goods
4 or services are excessive or not medically necessary unless
5 both the medical basis and the specific need for them are
6 fully and properly documented in the recipient's medical
7 record.
8 (g) Are authorized by a Medicaid provider or otherwise
9 authorized by the Medicaid program. Payment may be made under
10 the Medicaid program for emergency items or services
11 furnished, supervised, or caused to be furnished by a person
12 who has been suspended or terminated from the Medicaid program
13 or Medicare program by the Federal Government or any state.
14
15 The agency may deny payment for goods or services that are not
16 presented, as required in this subsection, which may include
17 denial of payment for goods or services furnished by a
18 provider or furnished by any other person at the direction of
19 or under the supervision of a provider.
20 (10) The agency may deny payment or require repayment
21 for inappropriate, medically unnecessary, or excessive goods
22 or services from the person furnishing them, the person under
23 whose supervision they were furnished, or the person causing
24 them to be furnished.
25 (14) The agency may seek any remedy provided by law,
26 including, but not limited to, the remedies provided in
27 subsections (12) and (15) and s. 812.035, if:
28 (a) The provider's license has not been renewed, or
29 has been revoked, suspended, or terminated, for cause, by the
30 licensing agency of any state;
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1 (b) The provider has failed to make available or has
2 refused access to Medicaid-related records to an auditor,
3 investigator, or other authorized employee or agent of the
4 agency, the Attorney General, a state attorney, or the Federal
5 Government;
6 (c) The provider has not furnished or has failed to
7 make available such Medicaid-related records as the agency has
8 found necessary to determine whether Medicaid payments are or
9 were due and the amounts thereof;
10 (d) The provider has failed to maintain medical
11 records made at the time of service, or prior to service if
12 prior authorization is required, demonstrating the necessity
13 and appropriateness of the goods or services rendered;
14 (e) The provider is not in compliance with provisions
15 of Medicaid provider publications that have been adopted by
16 reference as rules in the Florida Administrative Code; with
17 provisions of state or federal laws, rules, or regulations;
18 with provisions of the provider agreement between the agency
19 and the provider; or with certifications found on claim forms
20 or on transmittal forms for electronically submitted claims
21 that are submitted by the provider or authorized
22 representative, as such provisions apply to the Medicaid
23 program;
24 (f) The provider or person who ordered or prescribed
25 the care, services, or supplies has furnished, or ordered the
26 furnishing of, goods or services to a recipient which are
27 inappropriate, unnecessary, excessive, or harmful to the
28 recipient or are of inferior quality;
29 (g) The provider has demonstrated a pattern of failure
30 to provide goods or services that are medically necessary;
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1 (h) The provider or an authorized representative of
2 the provider, or a person who ordered or prescribed the goods
3 or services, has submitted or caused to be submitted a false
4 or a pattern of erroneous Medicaid claim, a request for a per
5 diem payment, or a request for payment of a capitation rate
6 claims that have resulted in overpayments to a provider or
7 that exceed those to which the provider was entitled under the
8 Medicaid program;
9 (i) The provider or an authorized representative of
10 the provider, or a person who has ordered or prescribed the
11 goods or services, has submitted or caused to be submitted a
12 Medicaid provider enrollment application, a request for prior
13 authorization for Medicaid services, a drug exception request,
14 or a Medicaid cost report that contains materially false or
15 incorrect information;
16 (j) The provider or an authorized representative of
17 the provider has collected from or billed a recipient or a
18 recipient's responsible party improperly for amounts that
19 should not have been so collected or billed by reason of the
20 provider's billing the Medicaid program for the same service;
21 (k) The provider or an authorized representative of
22 the provider has included in a cost report costs that are not
23 allowable under a Florida Title XIX reimbursement plan, after
24 the provider or authorized representative had been advised in
25 an audit exit conference or audit report that the costs were
26 not allowable;
27 (l) The provider is charged by information or
28 indictment with fraudulent billing practices. The sanction
29 applied for this reason is limited to suspension of the
30 provider's participation in the Medicaid program for the
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1 duration of the indictment unless the provider is found guilty
2 pursuant to the information or indictment;
3 (m) The provider or a person who has ordered, or
4 prescribed the goods or services is found liable for negligent
5 practice resulting in death or injury to the provider's
6 patient;
7 (n) The provider fails to demonstrate that it had
8 available during a specific audit or review period sufficient
9 quantities of goods, or sufficient time in the case of
10 services, to support the provider's billings to the Medicaid
11 program;
12 (o) The provider has failed to comply with the notice
13 and reporting requirements of s. 409.907;
14 (p) The agency has received reliable information of
15 patient abuse or neglect or of any act prohibited by s.
16 409.920; or
17 (q) The provider has failed to comply with an
18 agreed-upon repayment schedule.
19 (15) The agency shall impose any of the following
20 sanctions or disincentives on a provider or a person for any
21 of the acts described in subsection (14):
22 (a) Suspension for a specific period of time of not
23 more than 1 year. Suspension precludes participation in the
24 Medicaid program, which includes any action that results in a
25 claim for payment to the Medicaid program as a result of
26 furnishing, supervising a person who is furnishing, or causing
27 a person to furnish goods or services.
28 (b) Termination for a specific period of time of from
29 more than 1 year to 20 years. Termination precludes
30 participation in the Medicaid program, which includes any
31 action that results in a claim for payment to the Medicaid
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1 program as a result of furnishing, supervising a person who is
2 furnishing, or causing a person to furnish goods or services.
3 (c) Imposition of a fine of up to $5,000 for each
4 violation. Each day that an ongoing violation continues, such
5 as refusing to furnish Medicaid-related records or refusing
6 access to records, is considered, for the purposes of this
7 section, to be a separate violation. Each instance of
8 improper billing of a Medicaid recipient; each instance of
9 including an unallowable cost on a hospital or nursing home
10 Medicaid cost report after the provider or authorized
11 representative has been advised in an audit exit conference or
12 previous audit report of the cost unallowability; each
13 instance of furnishing a Medicaid recipient goods or
14 professional services that are inappropriate or of inferior
15 quality as determined by competent peer judgment; each
16 instance of knowingly submitting a materially false or
17 erroneous Medicaid provider enrollment application, request
18 for prior authorization for Medicaid services, drug exception
19 request, or cost report; each instance of inappropriate
20 prescribing of drugs for a Medicaid recipient as determined by
21 competent peer judgment; and each false or erroneous Medicaid
22 claim leading to an overpayment to a provider is considered,
23 for the purposes of this section, to be a separate violation.
24 (d) Immediate suspension, if the agency has received
25 information of patient abuse or neglect or of any act
26 prohibited by s. 409.920. Upon suspension, the agency must
27 issue an immediate final order under s. 120.569(2)(n).
28 (e) A fine, not to exceed $10,000, for a violation of
29 paragraph (14)(i).
30 (f) Imposition of liens against provider assets,
31 including, but not limited to, financial assets and real
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1 property, not to exceed the amount of fines or recoveries
2 sought, upon entry of an order determining that the such
3 moneys are due or recoverable.
4 (g) Prepayment reviews of claims for a specified
5 period of time.
6 (h) Comprehensive followup reviews of providers every
7 6 months to ensure that they are billing Medicaid correctly.
8 (i) Corrective-action plans that would remain in
9 effect for providers for up to 3 years and that would be
10 monitored by the agency every 6 months while in effect.
11 (j) Other remedies as permitted by law to effect the
12 recovery of a fine or overpayment.
13
14 The Secretary of Health Care Administration may make a
15 determination that imposition of a sanction or disincentive is
16 not in the best interest of the Medicaid program, in which
17 case a sanction or disincentive shall not be imposed.
18 (23) If the agency imposes an administrative sanction
19 under this section upon any provider or other person who is
20 regulated by another state entity for a violation of
21 subsection (12), subsection (13), or subsection (14), except
22 paragraphs (14)(e), (j), (k), (o), and (q), the agency shall
23 notify that other entity of the imposition of the sanction.
24 The Such notification must include the provider's or person's
25 name and license number and the specific reasons for sanction.
26 (24)(a) The agency may withhold Medicaid payments, in
27 whole or in part, to a provider upon receipt of reliable
28 evidence that the circumstances giving rise to the need for a
29 withholding of payments involve fraud, willful
30 misrepresentation, or abuse under the Medicaid program, or a
31 crime committed while rendering goods or services to Medicaid
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1 recipients, pending completion of legal proceedings. If it is
2 determined that fraud, willful misrepresentation, abuse, or a
3 crime did not occur, the payments withheld must be paid to the
4 provider within 14 days after the such determination with
5 interest at the rate of 10 percent a year. Any money withheld
6 in accordance with this paragraph shall be placed in a
7 suspended account, readily accessible to the agency, so that
8 any payment ultimately due the provider shall be made within
9 14 days.
10 (b) The agency may deny Medicaid payments if the goods
11 or services were furnished, supervised, or caused to be
12 furnished by a person who has been suspended or terminated
13 from the Medicaid program or Medicare program by the Federal
14 Government or any state. A claim for emergency services
15 furnished by a suspended or terminated person may be
16 authorized by the Medicaid program.
17 (c)(b) Overpayments owed to the agency bear interest
18 at the rate of 10 percent per year from the date of
19 determination of the overpayment by the agency, and payment
20 arrangements must be made at the conclusion of legal
21 proceedings. A provider who does not enter into or adhere to
22 an agreed-upon repayment schedule may be terminated by the
23 agency for nonpayment or partial payment.
24 (d)(c) The agency, upon entry of a final agency order,
25 a judgment or order of a court of competent jurisdiction, or a
26 stipulation or settlement, may collect the moneys owed by all
27 means allowable by law, including, but not limited to,
28 notifying any fiscal intermediary of Medicare benefits that
29 the state has a superior right of payment. Upon receipt of
30 such written notification, the Medicare fiscal intermediary
31 shall remit to the state the sum claimed.
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1 (e) The agency may institute amnesty projects to allow
2 Medicaid providers the opportunity to voluntarily repay
3 overpayments. The agency may adopt rules to administer such
4 programs.
5 (32) In accordance with federal law, Medicaid
6 recipients convicted of a crime pursuant to 42 U.S.C. 1320a-7b
7 may be limited, restricted, or suspended from Medicaid
8 eligibility for a period not to exceed 1 year, as determined
9 by the state Medicaid director.
10 Section 3. Paragraph (d) of subsection (2) and
11 paragraph (b) of subsection (5) of section 409.9131, Florida
12 Statutes, are amended to read:
13 409.9131 Special provisions relating to integrity of
14 the Medicaid program.--
15 (2) DEFINITIONS.--For purposes of this section, the
16 term:
17 (d) "Peer review" means an evaluation of the
18 professional practices of a Medicaid physician provider by a
19 peer or peers in order to assess the medical necessity,
20 appropriateness, and quality of care provided, as such care is
21 compared to that customarily furnished by the physician's
22 peers and to recognized health care standards, and to
23 determine whether the documentation in the physician's records
24 is adequate.
25 (5) DETERMINATIONS OF OVERPAYMENT.--In making a
26 determination of overpayment to a physician, the agency must:
27 (b) Refer all physician service claims for peer review
28 when the agency's preliminary analysis indicates that an
29 evaluation of the medical necessity, appropriateness, and
30 quality of care needs to be undertaken to determine a
31 potential overpayment, and before any formal proceedings are
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1 initiated against the physician, except as required by s.
2 409.913.
3 Section 4. This act shall take effect upon becoming a
4 law.
5
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7 SENATE SUMMARY
8 Authorizes the Agency for Health Care Administration to
impose mandatory enrollment in drug-therapy-management or
9 disease-management programs for certain categories of
recipients. Provides specified conditions for providers
10 to meet in order to submit claims to the Medicaid
program. Provides that claims may be denied if not
11 properly submitted. Provides that the agency may seek any
remedy under law if a provider submits specified false or
12 erroneous claims. Provides that suspension or termination
precludes participation in the Medicaid program. Directs
13 the agency to report administrative sanctions to
licensing authorities for certain violations. Permits the
14 agency to withhold payment to a provider under certain
circumstances. Permits the agency to deny payments to
15 terminated or suspended providers. Authorizes the agency
to implement amnesty projects for providers to
16 voluntarily repay overpayments. Provides for limiting,
restricting, or suspending Medicaid eligibility of
17 Medicaid recipients convicted of certain crimes or
offenses. Requires peer review for determining
18 overpayment under certain circumstances.
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