Florida Senate - 2010 CS for CS for CS for SB 752
By the Committees on Health and Human Services Appropriations;
Criminal Justice; and Health Regulation; and Senator Gaetz
603-04846-10 2010752c3
1 A bill to be entitled
2 An act relating to health care; amending s. 400.471,
3 F.S.; prohibiting the Agency for Health Care
4 Administration from issuing an initial license to a
5 home health agency for the purpose of opening a new
6 home health agency under certain conditions until a
7 specified date; prohibiting the agency from issuing a
8 change-of-ownership license to a home health agency
9 under certain conditions until a specified date;
10 providing an exception; amending s. 400.474, F.S.;
11 authorizing the agency to revoke a home health agency
12 license if the applicant or any controlling interest
13 has been sanctioned for acts specified under s.
14 400.471(10), F.S.; amending s. 408.815, F.S.; revising
15 the grounds upon which the agency may deny or revoke
16 an application for an initial license, a change-of
17 ownership license, or a licensure renewal for certain
18 health care entities listed in s. 408.802, F.S.;
19 amending s. 408.910, F.S.; revising the list of
20 employers who are eligible to enroll in the Florida
21 Health Choices Program; revising the membership of the
22 board of directors of the Florida Health Choices,
23 Inc.; requiring the President of the Senate and the
24 Speaker of the House of Representatives to initially
25 appoint members to the board of directors for
26 staggered terms; requiring that the members of the
27 board appoint new members to the board of directors
28 after a specified date, subject to Senate
29 confirmation; deleting a provision that prohibits
30 board members from serving for more than a certain
31 number of consecutive years; amending s. 409.907,
32 F.S.; extending the number of years that Medicaid
33 providers must retain Medicaid recipient records;
34 adding additional requirements to the Medicaid
35 provider agreement; revising applicability of
36 screening requirements; revising conditions under
37 which the agency is authorized to deny a Medicaid
38 provider application; amending s. 409.912, F.S.;
39 revising requirements for Medicaid prepaid, fixed-sum,
40 and managed care contracts; revising requirements for
41 Medicaid durable medical equipment providers;
42 repealing s. 409.9122(13), F.S., relating to the
43 enrollee assignment process of Medicaid managed
44 prepaid health plans for those Medicaid managed
45 prepaid health plans operating in Miami-Dade County;
46 amending s. 409.913, F.S.; removing a required element
47 from the joint Medicaid fraud and abuse report
48 submitted by the agency and the Medicaid Fraud Control
49 Unit of the Department of Legal Affairs; extending the
50 number of years that Medicaid providers must retain
51 Medicaid recipient records; authorizing the Medicaid
52 program integrity staff to immediately suspend or
53 terminate a Medicaid provider for engaging in
54 specified conduct; removing a requirement for the
55 agency to hold suspended Medicaid payments in a
56 separate account; authorizing the agency to deny
57 payment or require repayment to Medicaid providers
58 convicted of certain crimes; authorizing the agency to
59 terminate a Medicaid provider if the provider fails to
60 reimburse a fine determined by a final order;
61 authorizing the agency to withhold Medicaid
62 reimbursement to a Medicaid provider that fails to pay
63 a fine determined by a final order, fails to enter
64 into a repayment plan, or fails to comply with a
65 repayment plan or settlement agreement; requiring the
66 biennial review of Medicaid fraud and abuse by the
67 Office of Program Policy Analysis and Government
68 Accountability to include a report on the Medicaid
69 Fraud Control Unit within the Department of Legal
70 Affairs; amending s. 409.9203, F.S.; providing that
71 certain state employees are ineligible from receiving
72 a reward for reporting Medicaid fraud; amending s.
73 456.001, F.S.; defining the term “affiliate” or
74 “affiliated person” as it relates to health
75 professions and occupations; amending s. 456.041,
76 F.S.; requiring the Department of Health to include
77 administrative complaints and any conviction
78 information relating to the practitioner’s profile;
79 providing a disclaimer; amending s. 456.0635, F.S.;
80 revising the grounds under which the Department of
81 Health or corresponding board is required to refuse to
82 admit a candidate to an examination and refuse to
83 issue or renew a license, certificate, or registration
84 of a health care practitioner; providing an exception;
85 amending s. 456.072, F.S.; clarifying a ground under
86 which disciplinary actions may be taken; amending s.
87 456.073, F.S.; revising applicability of
88 investigations and administrative complaints to
89 include Medicaid fraud; amending s. 456.074, F.S.;
90 authorizing the Department of Health to issue an
91 emergency order suspending the license of any person
92 licensed under ch. 456, F.S., who engages in specified
93 criminal conduct; amending s. 499.01, F.S.; exempting
94 certain persons from requirements for medical device
95 manufacturer permits; providing an effective date.
96
97 Be It Enacted by the Legislature of the State of Florida:
98
99 Section 1. Subsection (11) of section 400.471, Florida
100 Statutes, is amended to read:
101 400.471 Application for license; fee.—
102 (11)(a) The agency may not issue an initial license to a
103 home health agency under part II of chapter 408 or this part for
104 the purpose of opening a new home health agency until July 1,
105 2012 2010, in any county that has at least one actively licensed
106 home health agency and a population of persons 65 years of age
107 or older, as indicated in the most recent population estimates
108 published by the Executive Office of the Governor, of fewer than
109 1,200 per home health agency. In such counties, for any
110 application received by the agency prior to July 1, 2009, which
111 has been deemed by the agency to be complete except for proof of
112 accreditation, the agency may issue an initial ownership license
113 only if the applicant has applied for accreditation before May
114 1, 2009, from an accrediting organization that is recognized by
115 the agency.
116 (b) Effective October 1, 2009, the agency may not issue a
117 change of ownership license to a home health agency under part
118 II of chapter 408 or this part until July 1, 2012 2010, in any
119 county that has at least one actively licensed home health
120 agency and a population of persons 65 years of age or older, as
121 indicated in the most recent population estimates published by
122 the Executive Office of the Governor, of fewer than 1,200 per
123 home health agency. In such counties, for any application
124 received by the agency before prior to October 1, 2009, which
125 has been deemed by the agency to be complete except for proof of
126 accreditation, the agency may issue a change of ownership
127 license only if the applicant has applied for accreditation
128 before August 1, 2009, from an accrediting organization that is
129 recognized by the agency. This paragraph does not apply to an
130 application for a change in ownership from an existing home
131 health agency that is accredited, has been licensed by the state
132 at least 5 years, and is in good standing with the agency.
133 Section 2. Subsection (8) is added to section 400.474,
134 Florida Statutes, to read:
135 400.474 Administrative penalties.—
136 (8) The agency may revoke the license of a home health
137 agency that is not eligible for licensure renewal under s.
138 400.471(10).
139 Section 3. Subsections (1) and (4) of section 408.815,
140 Florida Statutes, are amended, and subsection (5) is added to
141 that section, to read:
142 408.815 License or application denial; revocation.—
143 (1) In addition to the grounds provided in authorizing
144 statutes, grounds that may be used by the agency for denying and
145 revoking a license or change of ownership application include
146 any of the following actions by a controlling interest:
147 (a) False representation of a material fact in the license
148 application or omission of any material fact from the
149 application.
150 (b) An intentional or negligent act materially affecting
151 the health or safety of a client of the provider.
152 (c) A violation of this part, authorizing statutes, or
153 applicable rules.
154 (d) A demonstrated pattern of deficient performance.
155 (e) The applicant, licensee, or controlling interest has
156 been or is currently excluded, suspended, or terminated from
157 participation in the state Medicaid program, the Medicaid
158 program of any other state, or the Medicare program.
159 (f) The applicant, licensee, or controlling interest is or
160 was an administrator or controlling interest in a facility or
161 entity during the period an event that caused or contributed to
162 the facility or entity being excluded, suspended, or terminated
163 from participation in the state Medicaid program, the Medicaid
164 program of any other state, or the Medicare program.
165 (4) In addition to the grounds provided in authorizing
166 statutes, the agency shall deny an application for an initial a
167 license or a change-of-ownership license renewal if the
168 applicant or a person having a controlling interest in the an
169 applicant has been:
170 (a) Has been convicted of, or entered enters a plea of
171 guilty or nolo contendere to, regardless of adjudication, a
172 felony under chapter 409, chapter 817, chapter 893, or a similar
173 felony offense committed in another state or jurisdiction 21
174 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the
175 sentence and any subsequent period of probation for such
176 conviction convictions or plea ended more than 15 years before
177 prior to the date of the application;
178 (b) Has been convicted of, or entered a plea of guilty or
179 nolo contendere to, regardless of adjudication, a felony under
180 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the
181 sentence and any subsequent period of probation for such
182 conviction or plea ended more than 15 years before the date of
183 the application;
184 (c)(b) Has been terminated for cause from the Florida
185 Medicaid program pursuant to s. 409.913, unless the applicant
186 has been in good standing with the Florida Medicaid program for
187 the most recent 5 years; or
188 (d)(c) Has been terminated for cause, pursuant to the
189 appeals procedures established by the state, or Federal
190 Government, from the federal Medicare program or from any other
191 state Medicaid program, unless the applicant has been in good
192 standing with a state Medicaid program or the federal Medicare
193 program for the most recent 5 years and the termination occurred
194 at least 20 years before prior to the date of the application;
195 or.
196 (e) Is currently listed on the United States Department of
197 Health and Human Services Office of Inspector General’s List of
198 Excluded Individuals and Entities.
199 (5) In addition to the grounds provided in authorizing
200 statutes, the agency shall deny an application for licensure
201 renewal if the applicant or a person having a controlling
202 interest in the applicant:
203 (a) Has been convicted of, or entered a plea of guilty or
204 nolo contendere to, regardless of adjudication, a felony under
205 chapter 409, chapter 817, chapter 893, or a similar felony
206 offense committed in another state or jurisdiction since July 1,
207 2009;
208 (b) Has been convicted of, or entered a plea of guilty or
209 nolo contendere to, regardless of adjudication, a felony under
210 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396 since July 1,
211 2009;
212 (c) Has been terminated for cause from the Florida Medicaid
213 program pursuant to s. 409.913, unless the applicant has been in
214 good standing with the Florida Medicaid program for the most
215 recent 5 years;
216 (d) Has been terminated for cause, pursuant to the appeals
217 procedures established by the state, from any other state
218 Medicaid program, unless the applicant has been in good standing
219 with a state Medicaid program for the most recent 5 years and
220 the termination occurred at least 20 years before the date of
221 the application; or
222 (e) Is currently listed on the United States Department of
223 Health and Human Services Office of Inspector General’s List of
224 Excluded Individuals and Entities.
225 Section 4. Paragraph (a) of subsection (4) and subsection
226 (11) of section 408.910, Florida Statutes, are amended to read:
227 408.910 Florida Health Choices Program.—
228 (4) ELIGIBILITY AND PARTICIPATION.—Participation in the
229 program is voluntary and shall be available to employers,
230 individuals, vendors, and health insurance agents as specified
231 in this subsection.
232 (a) Employers eligible to enroll in the program include:
233 1. Employers that have 1 to 50 employees.
234 2. Fiscally constrained counties described in s. 218.67.
235 3. Municipalities having populations of fewer than 50,000
236 residents.
237 4. School districts in fiscally constrained counties.
238 5. State universities and community colleges.
239 (11) CORPORATION.—There is created the Florida Health
240 Choices, Inc., which shall be registered, incorporated,
241 organized, and operated in compliance with part III of chapter
242 112 and chapters 119, 286, and 617. The purpose of the
243 corporation is to administer the program created in this section
244 and to conduct such other business as may further the
245 administration of the program.
246 (a)1. The corporation shall be governed by a five-member
247 15-member board of directors consisting of:
248 1. Three ex officio, nonvoting members to include:
249 a. The Secretary of Health Care Administration or a
250 designee with expertise in health care services.
251 b. The Secretary of Management Services or a designee with
252 expertise in state employee benefits.
253 c. The commissioner of the Office of Insurance Regulation
254 or a designee with expertise in insurance regulation.
255 a.2. One member Four members appointed by and serving at
256 the pleasure of the Governor.
257 b.3. Two Four members appointed by and serving at the
258 pleasure of the President of the Senate.
259 c.4. Two Four members appointed by and serving at the
260 pleasure of the Speaker of the House of Representatives.
261 2.5. Board members may not include insurers, health
262 insurance agents or brokers, health care providers, health
263 maintenance organizations, prepaid service providers, or any
264 other entity, affiliate or subsidiary of eligible vendors.
265 (b)1. Members shall be appointed for terms of up to 4 3
266 years. In order to establish staggered terms, for the initial
267 appointments the President of the Senate and the Speaker of the
268 House of Representatives shall each appoint one member to a 2
269 year term and one member to a 4-year term. Any member is
270 eligible for reappointment. A vacancy on the board shall be
271 filled for the unexpired portion of the term in the same manner
272 as the original appointment.
273 2. Beginning July 1, 2011, the members of the board of
274 directors shall appoint new members to the board of directors,
275 subject to confirmation by the Senate.
276 (c) The board shall select a chief executive officer for
277 the corporation who shall be responsible for the selection of
278 such other staff as may be authorized by the corporation’s
279 operating budget as adopted by the board.
280 (d) Board members are entitled to receive, from funds of
281 the corporation, reimbursement for per diem and travel expenses
282 as provided by s. 112.061. No other compensation is authorized.
283 (e) There is no liability on the part of, and no cause of
284 action shall arise against, any member of the board or its
285 employees or agents for any action taken by them in the
286 performance of their powers and duties under this section.
287 (f) The board shall develop and adopt bylaws and other
288 corporate procedures as necessary for the operation of the
289 corporation and carrying out the purposes of this section. The
290 bylaws shall:
291 1. Specify procedures for selection of officers and
292 qualifications for reappointment, provided that no board member
293 shall serve more than 9 consecutive years.
294 2. Require an annual membership meeting that provides an
295 opportunity for input and interaction with individual
296 participants in the program.
297 3. Specify policies and procedures regarding conflicts of
298 interest, including the provisions of part III of chapter 112,
299 which prohibit a member from participating in any decision that
300 would inure to the benefit of the member or the organization
301 that employs the member. The policies and procedures shall also
302 require public disclosure of the interest that prevents the
303 member from participating in a decision on a particular matter.
304 (g) The corporation may exercise all powers granted to it
305 under chapter 617 necessary to carry out the purposes of this
306 section, including, but not limited to, the power to receive and
307 accept grants, loans, or advances of funds from any public or
308 private agency and to receive and accept from any source
309 contributions of money, property, labor, or any other thing of
310 value to be held, used, and applied for the purposes of this
311 section.
312 (h) The corporation may establish technical advisory panels
313 consisting of interested parties, including consumers, health
314 care providers, individuals with expertise in insurance
315 regulation, and insurers.
316 (i) The corporation shall:
317 1. Determine eligibility of employers, vendors,
318 individuals, and agents in accordance with subsection (4).
319 2. Establish procedures necessary for the operation of the
320 program, including, but not limited to, procedures for
321 application, enrollment, risk assessment, risk adjustment, plan
322 administration, performance monitoring, and consumer education.
323 3. Arrange for collection of contributions from
324 participating employers and individuals.
325 4. Arrange for payment of premiums and other appropriate
326 disbursements based on the selections of products and services
327 by the individual participants.
328 5. Establish criteria for disenrollment of participating
329 individuals based on failure to pay the individual’s share of
330 any contribution required to maintain enrollment in selected
331 products.
332 6. Establish criteria for exclusion of vendors pursuant to
333 paragraph (4)(d).
334 7. Develop and implement a plan for promoting public
335 awareness of and participation in the program.
336 8. Secure staff and consultant services necessary to the
337 operation of the program.
338 9. Establish policies and procedures regarding
339 participation in the program for individuals, vendors, health
340 insurance agents, and employers.
341 10. Develop a plan, in coordination with the Department of
342 Revenue, to establish tax credits or refunds for employers that
343 participate in the program. The corporation shall submit the
344 plan to the Governor, the President of the Senate, and the
345 Speaker of the House of Representatives by January 1, 2009.
346 Section 5. Paragraph (c) of subsection (3) of section
347 409.907, Florida Statutes, is amended, paragraph (k) is added to
348 that subsection, and subsection (8), paragraph (b) of subsection
349 (9), and subsection (10) of that section are amended, to read:
350 409.907 Medicaid provider agreements.—The agency may make
351 payments for medical assistance and related services rendered to
352 Medicaid recipients only to an individual or entity who has a
353 provider agreement in effect with the agency, who is performing
354 services or supplying goods in accordance with federal, state,
355 and local law, and who agrees that no person shall, on the
356 grounds of handicap, race, color, or national origin, or for any
357 other reason, be subjected to discrimination under any program
358 or activity for which the provider receives payment from the
359 agency.
360 (3) The provider agreement developed by the agency, in
361 addition to the requirements specified in subsections (1) and
362 (2), shall require the provider to:
363 (c) Retain all medical and Medicaid-related records for a
364 period of 6 5 years to satisfy all necessary inquiries by the
365 agency.
366 (k) Report any change of any principal of the provider,
367 including any officer, director, agent, managing employee, or
368 affiliated person, or any partner or shareholder who has an
369 ownership interest equal to 5 percent or more in the provider.
370 The provider must report changes to the agency no later than 30
371 days after the change occurs. Reporting changes in controlling
372 interests to the agency pursuant to s. 408.810(3) shall serve as
373 compliance with this paragraph for hospitals licensed under
374 chapter 395 and nursing homes licensed under chapter 400.
375 (8)(a) Each provider, or each principal of the provider if
376 the provider is a corporation, partnership, association, or
377 other entity, seeking to participate in the Medicaid program
378 must submit a complete set of his or her fingerprints to the
379 agency for the purpose of conducting a criminal history record
380 check. Principals of the provider include any officer, director,
381 billing agent, managing employee, or affiliated person, or any
382 partner or shareholder who has an ownership interest equal to 5
383 percent or more in the provider. However, for hospitals licensed
384 under chapter 395 and nursing homes licensed under chapter 400,
385 principals of the provider are those who meet the definition of
386 a controlling interest in s. 408.803(7). A director of a not
387 for-profit corporation or organization is not a principal for
388 purposes of a background investigation as required by this
389 section if the director: serves solely in a voluntary capacity
390 for the corporation or organization, does not regularly take
391 part in the day-to-day operational decisions of the corporation
392 or organization, receives no remuneration from the not-for
393 profit corporation or organization for his or her service on the
394 board of directors, has no financial interest in the not-for
395 profit corporation or organization, and has no family members
396 with a financial interest in the not-for-profit corporation or
397 organization; and if the director submits an affidavit, under
398 penalty of perjury, to this effect to the agency and the not
399 for-profit corporation or organization submits an affidavit,
400 under penalty of perjury, to this effect to the agency as part
401 of the corporation’s or organization’s Medicaid provider
402 agreement application. Notwithstanding the above, the agency may
403 require a background check for any person reasonably suspected
404 by the agency to have been convicted of a crime. This subsection
405 does shall not apply to:
406 1. A hospital licensed under chapter 395;
407 2. A nursing home licensed under chapter 400;
408 3. A hospice licensed under chapter 400;
409 4. An assisted living facility licensed under chapter 429;
410 1.5. A unit of local government, except that requirements
411 of this subsection apply to nongovernmental providers and
412 entities when contracting with the local government to provide
413 Medicaid services. The actual cost of the state and national
414 criminal history record checks must be borne by the
415 nongovernmental provider or entity; or
416 2.6. Any business that derives more than 50 percent of its
417 revenue from the sale of goods to the final consumer, and the
418 business or its controlling parent either is required to file a
419 form 10-K or other similar statement with the Securities and
420 Exchange Commission or has a net worth of $50 million or more.
421 (b) Background screening shall be conducted in accordance
422 with chapter 435 and s. 408.809. The agency shall submit the
423 fingerprints to the Department of Law Enforcement. The
424 department shall conduct a state criminal-background
425 investigation and forward the fingerprints to the Federal Bureau
426 of Investigation for a national criminal-history record check.
427 The cost of the state and national criminal record check shall
428 be borne by the provider.
429 (c) The agency may permit a provider to participate in the
430 Medicaid program pending the results of the criminal record
431 check. However, such permission is fully revocable if the record
432 check reveals any crime-related history as provided in
433 subsection (10).
434 (c)(d) Proof of compliance with the requirements of level 2
435 screening under s. 435.04 conducted within 12 months prior to
436 the date that the Medicaid provider application is submitted to
437 the agency shall fulfill the requirements of this subsection.
438 Proof of compliance with the requirements of level 1 screening
439 under s. 435.03 conducted within 12 months prior to the date
440 that the Medicaid provider application is submitted to the
441 agency shall meet the requirement that the Department of Law
442 Enforcement conduct a state criminal history record check.
443 (9) Upon receipt of a completed, signed, and dated
444 application, and completion of any necessary background
445 investigation and criminal history record check, the agency must
446 either:
447 (b) Deny the application if the agency finds that it is in
448 the best interest of the Medicaid program to do so. The agency
449 may consider any the factors listed in subsection (10), as well
450 as any other factor that could affect the effective and
451 efficient administration of the program, including, but not
452 limited to, the applicant’s demonstrated ability to provide
453 services, conduct business, and operate a financially viable
454 concern; the current availability of medical care, services, or
455 supplies to recipients, taking into account geographic location
456 and reasonable travel time; the number of providers of the same
457 type already enrolled in the same geographic area; and the
458 credentials, experience, success, and patient outcomes of the
459 provider for the services that it is making application to
460 provide in the Medicaid program. The agency shall deny the
461 application if the agency finds that a provider; any officer,
462 director, agent, managing employee, or affiliated person; or any
463 principal, partner, or shareholder having an ownership interest
464 equal to 5 percent or greater in the provider if the provider is
465 a corporation, partnership, or other business entity, has failed
466 to pay all outstanding fines or overpayments assessed by final
467 order of the agency or final order of the Centers for Medicare
468 and Medicaid Services, not subject to further appeal, unless the
469 provider agrees to a repayment plan that includes withholding
470 Medicaid reimbursement until the amount due is paid in full.
471 (10) The agency shall deny the application if may consider
472 whether the provider, or any officer, director, agent, managing
473 employee, or affiliated person, or any principal, partner, or
474 shareholder having an ownership interest equal to 5 percent or
475 greater in the provider if the provider is a corporation,
476 partnership, or other business entity, has committed an offense
477 listed in s. 409.913(13), and may deny the application if one of
478 these persons has:
479 (a) Made a false representation or omission of any material
480 fact in making the application, including the submission of an
481 application that conceals the controlling or ownership interest
482 of any officer, director, agent, managing employee, affiliated
483 person, or principal, partner, or shareholder who may not be
484 eligible to participate;
485 (b) Been or is currently excluded, suspended, terminated
486 from, or has involuntarily withdrawn from participation in,
487 Florida’s Medicaid program or any other state’s Medicaid
488 program, or from participation in any other governmental or
489 private health care or health insurance program;
490 (c) Been convicted of a criminal offense relating to the
491 delivery of any goods or services under Medicaid or Medicare or
492 any other public or private health care or health insurance
493 program including the performance of management or
494 administrative services relating to the delivery of goods or
495 services under any such program;
496 (d) Been convicted under federal or state law of a criminal
497 offense related to the neglect or abuse of a patient in
498 connection with the delivery of any health care goods or
499 services;
500 (c)(e) Been convicted under federal or state law of a
501 criminal offense relating to the unlawful manufacture,
502 distribution, prescription, or dispensing of a controlled
503 substance;
504 (d)(f) Been convicted of any criminal offense relating to
505 fraud, theft, embezzlement, breach of fiduciary responsibility,
506 or other financial misconduct;
507 (e)(g) Been convicted under federal or state law of a crime
508 punishable by imprisonment of a year or more which involves
509 moral turpitude;
510 (f)(h) Been convicted in connection with the interference
511 or obstruction of any investigation into any criminal offense
512 listed in this subsection;
513 (g)(i) Been found to have violated federal or state laws,
514 rules, or regulations governing Florida’s Medicaid program or
515 any other state’s Medicaid program, the Medicare program, or any
516 other publicly funded federal or state health care or health
517 insurance program, and been sanctioned accordingly;
518 (h)(j) Been previously found by a licensing, certifying, or
519 professional standards board or agency to have violated the
520 standards or conditions relating to licensure or certification
521 or the quality of services provided; or
522 (i)(k) Failed to pay any fine or overpayment properly
523 assessed under the Medicaid program in which no appeal is
524 pending or after resolution of the proceeding by stipulation or
525 agreement, unless the agency has issued a specific letter of
526 forgiveness or has approved a repayment schedule to which the
527 provider agrees to adhere.
528
529 If the agency determines a provider did not participate or
530 acquiesce in an offense specified in s. 409.913(13), the agency
531 is not required to deny the provider application.
532 Section 6. Subsections (10), (32), and (48) of section
533 409.912, Florida Statutes, are amended to read:
534 409.912 Cost-effective purchasing of health care.—The
535 agency shall purchase goods and services for Medicaid recipients
536 in the most cost-effective manner consistent with the delivery
537 of quality medical care. To ensure that medical services are
538 effectively utilized, the agency may, in any case, require a
539 confirmation or second physician’s opinion of the correct
540 diagnosis for purposes of authorizing future services under the
541 Medicaid program. This section does not restrict access to
542 emergency services or poststabilization care services as defined
543 in 42 C.F.R. part 438.114. Such confirmation or second opinion
544 shall be rendered in a manner approved by the agency. The agency
545 shall maximize the use of prepaid per capita and prepaid
546 aggregate fixed-sum basis services when appropriate and other
547 alternative service delivery and reimbursement methodologies,
548 including competitive bidding pursuant to s. 287.057, designed
549 to facilitate the cost-effective purchase of a case-managed
550 continuum of care. The agency shall also require providers to
551 minimize the exposure of recipients to the need for acute
552 inpatient, custodial, and other institutional care and the
553 inappropriate or unnecessary use of high-cost services. The
554 agency shall contract with a vendor to monitor and evaluate the
555 clinical practice patterns of providers in order to identify
556 trends that are outside the normal practice patterns of a
557 provider’s professional peers or the national guidelines of a
558 provider’s professional association. The vendor must be able to
559 provide information and counseling to a provider whose practice
560 patterns are outside the norms, in consultation with the agency,
561 to improve patient care and reduce inappropriate utilization.
562 The agency may mandate prior authorization, drug therapy
563 management, or disease management participation for certain
564 populations of Medicaid beneficiaries, certain drug classes, or
565 particular drugs to prevent fraud, abuse, overuse, and possible
566 dangerous drug interactions. The Pharmaceutical and Therapeutics
567 Committee shall make recommendations to the agency on drugs for
568 which prior authorization is required. The agency shall inform
569 the Pharmaceutical and Therapeutics Committee of its decisions
570 regarding drugs subject to prior authorization. The agency is
571 authorized to limit the entities it contracts with or enrolls as
572 Medicaid providers by developing a provider network through
573 provider credentialing. The agency may competitively bid single
574 source-provider contracts if procurement of goods or services
575 results in demonstrated cost savings to the state without
576 limiting access to care. The agency may limit its network based
577 on the assessment of beneficiary access to care, provider
578 availability, provider quality standards, time and distance
579 standards for access to care, the cultural competence of the
580 provider network, demographic characteristics of Medicaid
581 beneficiaries, practice and provider-to-beneficiary standards,
582 appointment wait times, beneficiary use of services, provider
583 turnover, provider profiling, provider licensure history,
584 previous program integrity investigations and findings, peer
585 review, provider Medicaid policy and billing compliance records,
586 clinical and medical record audits, and other factors. Providers
587 shall not be entitled to enrollment in the Medicaid provider
588 network. The agency shall determine instances in which allowing
589 Medicaid beneficiaries to purchase durable medical equipment and
590 other goods is less expensive to the Medicaid program than long
591 term rental of the equipment or goods. The agency may establish
592 rules to facilitate purchases in lieu of long-term rentals in
593 order to protect against fraud and abuse in the Medicaid program
594 as defined in s. 409.913. The agency may seek federal waivers
595 necessary to administer these policies.
596 (10) The agency shall not contract on a prepaid or fixed
597 sum basis for Medicaid services with an entity which knows or
598 reasonably should know that any principal, officer, director,
599 agent, managing employee, or owner of stock or beneficial
600 interest in excess of 5 percent common or preferred stock, or
601 the entity itself, has been found guilty of, regardless of
602 adjudication, or entered a plea of nolo contendere, or guilty,
603 to:
604 (a) An offense listed in s. 408.809, s. 409.913(13), or s.
605 435.04 Fraud;
606 (b) Violation of federal or state antitrust statutes,
607 including those proscribing price fixing between competitors and
608 the allocation of customers among competitors;
609 (c) Commission of a felony involving embezzlement, theft,
610 forgery, income tax evasion, bribery, falsification or
611 destruction of records, making false statements, receiving
612 stolen property, making false claims, or obstruction of justice;
613 or
614 (d) Any crime in any jurisdiction which directly relates to
615 the provision of health services on a prepaid or fixed-sum
616 basis.
617 (32) Each managed care plan that is under contract with the
618 agency to provide health care services to Medicaid recipients
619 shall annually conduct a background check with the Florida
620 Department of Law Enforcement of all persons with ownership
621 interest of 5 percent or more or executive management
622 responsibility for the managed care plan and shall submit to the
623 agency information concerning any such person who has been found
624 guilty of, regardless of adjudication, or has entered a plea of
625 nolo contendere or guilty to, any of the offenses listed in s.
626 408.809, s. 409.913(13), or s. 435.04 s. 435.03.
627 (48)(a) A provider is not entitled to enrollment in the
628 Medicaid provider network. The agency may implement a Medicaid
629 fee-for-service provider network controls, including, but not
630 limited to, competitive procurement and provider credentialing.
631 If a credentialing process is used, the agency may limit its
632 provider network based upon the following considerations:
633 beneficiary access to care, provider availability, provider
634 quality standards and quality assurance processes, cultural
635 competency, demographic characteristics of beneficiaries,
636 practice standards, service wait times, provider turnover,
637 provider licensure and accreditation history, program integrity
638 history, peer review, Medicaid policy and billing compliance
639 records, clinical and medical record audit findings, and such
640 other areas that are considered necessary by the agency to
641 ensure the integrity of the program.
642 (b) The agency shall limit its network of durable medical
643 equipment and medical supply providers. For dates of service
644 after January 1, 2009, the agency shall limit payment for
645 durable medical equipment and supplies to providers that meet
646 all the requirements of this paragraph.
647 1. Providers must be accredited by a Centers for Medicare
648 and Medicaid Services deemed accreditation organization for
649 suppliers of durable medical equipment, prosthetics, orthotics,
650 and supplies. The provider must maintain accreditation and is
651 subject to unannounced reviews by the accrediting organization.
652 2. Providers must provide the services or supplies directly
653 to the Medicaid recipient or caregiver at the provider location
654 or recipient’s residence or send the supplies directly to the
655 recipient’s residence with receipt of mailed delivery.
656 Subcontracting or consignment of the service or supply to a
657 third party is prohibited.
658 3. Notwithstanding subparagraph 2., a durable medical
659 equipment provider may store nebulizers at a physician’s office
660 for the purpose of having the physician’s staff issue the
661 equipment if it meets all of the following conditions:
662 a. The physician must document the medical necessity and
663 need to prevent further deterioration of the patient’s
664 respiratory status by the timely delivery of the nebulizer in
665 the physician’s office.
666 b. The durable medical equipment provider must have written
667 documentation of the competency and training by a Florida
668 licensed registered respiratory therapist of any durable medical
669 equipment staff who participate in the training of physician
670 office staff for the use of nebulizers, including cleaning,
671 warranty, and special needs of patients.
672 c. The physician’s office must have documented the training
673 and competency of any staff member who initiates the delivery of
674 nebulizers to patients. The durable medical equipment provider
675 must maintain copies of all physician office training.
676 d. The physician’s office must maintain inventory records
677 of stored nebulizers, including documentation of the durable
678 medical equipment provider source.
679 e. A physician contracted with a Medicaid durable medical
680 equipment provider may not have a financial relationship with
681 that provider or receive any financial gain from the delivery of
682 nebulizers to patients.
683 4. Providers must have a physical business location and a
684 functional landline business phone. The location must be within
685 the state or not more than 50 miles from the Florida state line.
686 The agency may make exceptions for providers of durable medical
687 equipment or supplies not otherwise available from other
688 enrolled providers located within the state.
689 5. Physical business locations must be clearly identified
690 as a business that furnishes durable medical equipment or
691 medical supplies by signage that can be read from 20 feet away.
692 The location must be readily accessible to the public during
693 normal, posted business hours and must operate no less than 5
694 hours per day and no less than 5 days per week, with the
695 exception of scheduled and posted holidays. The location may not
696 be located within or at the same numbered street address as
697 another enrolled Medicaid durable medical equipment or medical
698 supply provider or as an enrolled Medicaid pharmacy that is also
699 enrolled as a durable medical equipment provider. A licensed
700 orthotist or prosthetist that provides only orthotic or
701 prosthetic devices as a Medicaid durable medical equipment
702 provider is exempt from the provisions in this paragraph.
703 6. Providers must maintain a stock of durable medical
704 equipment and medical supplies on site that is readily available
705 to meet the needs of the durable medical equipment business
706 location’s customers.
707 7. Providers must provide a surety bond of $50,000 for each
708 provider location, up to a maximum of 5 bonds statewide or an
709 aggregate bond of $250,000 statewide, as identified by Federal
710 Employer Identification Number. Providers who post a statewide
711 or an aggregate bond must identify all of their locations in any
712 Medicaid durable medical equipment and medical supply provider
713 enrollment application or bond renewal. Each provider location’s
714 surety bond must be renewed annually and the provider must
715 submit proof of renewal even if the original bond is a
716 continuous bond. A licensed orthotist or prosthetist that
717 provides only orthotic or prosthetic devices as a Medicaid
718 durable medical equipment provider is exempt from the provisions
719 in this paragraph.
720 8. Providers must obtain a level 2 background screening, in
721 accordance with chapter 435 and s. 408.809 as provided under s.
722 435.04, for each provider employee in direct contact with or
723 providing direct services to recipients of durable medical
724 equipment and medical supplies in their homes. This requirement
725 includes, but is not limited to, repair and service technicians,
726 fitters, and delivery staff. The provider shall pay for the cost
727 of the background screening.
728 9. The following providers are exempt from the requirements
729 of subparagraphs 1. and 7.:
730 a. Durable medical equipment providers owned and operated
731 by a government entity.
732 b. Durable medical equipment providers that are operating
733 within a pharmacy that is currently enrolled as a Medicaid
734 pharmacy provider.
735 c. Active, Medicaid-enrolled orthopedic physician groups,
736 primarily owned by physicians, which provide only orthotic and
737 prosthetic devices.
738 Section 7. Subsection (13) of section 409.9122, Florida
739 Statutes, is repealed.
740 Section 8. Section 409.913, Florida Statutes, is amended to
741 read:
742 409.913 Oversight of the integrity of the Medicaid
743 program.—The agency shall operate a program to oversee the
744 activities of Florida Medicaid recipients, and providers and
745 their representatives, to ensure that fraudulent and abusive
746 behavior and neglect of recipients occur to the minimum extent
747 possible, and to recover overpayments and impose sanctions as
748 appropriate. Beginning January 1, 2003, and each year
749 thereafter, the agency and the Medicaid Fraud Control Unit of
750 the Department of Legal Affairs shall submit a joint report to
751 the Legislature documenting the effectiveness of the state’s
752 efforts to control Medicaid fraud and abuse and to recover
753 Medicaid overpayments during the previous fiscal year. The
754 report must describe the number of cases opened and investigated
755 each year; the sources of the cases opened; the disposition of
756 the cases closed each year; the amount of overpayments alleged
757 in preliminary and final audit letters; the number and amount of
758 fines or penalties imposed; any reductions in overpayment
759 amounts negotiated in settlement agreements or by other means;
760 the amount of final agency determinations of overpayments; the
761 amount deducted from federal claiming as a result of
762 overpayments; the amount of overpayments recovered each year;
763 the amount of cost of investigation recovered each year; the
764 average length of time to collect from the time the case was
765 opened until the overpayment is paid in full; the amount
766 determined as uncollectible and the portion of the uncollectible
767 amount subsequently reclaimed from the Federal Government; the
768 number of providers, by type, that are terminated from
769 participation in the Medicaid program as a result of fraud and
770 abuse; and all costs associated with discovering and prosecuting
771 cases of Medicaid overpayments and making recoveries in such
772 cases. The report must also document actions taken to prevent
773 overpayments and the number of providers prevented from
774 enrolling in or reenrolling in the Medicaid program as a result
775 of documented Medicaid fraud and abuse and must include policy
776 recommendations necessary to prevent or recover overpayments and
777 changes necessary to prevent and detect Medicaid fraud. All
778 policy recommendations in the report must include a detailed
779 fiscal analysis, including, but not limited to, implementation
780 costs, estimated savings to the Medicaid program, and the return
781 on investment. The agency must submit the policy recommendations
782 and fiscal analyses in the report to the appropriate estimating
783 conference, pursuant to s. 216.137, by February 15 of each year.
784 The agency and the Medicaid Fraud Control Unit of the Department
785 of Legal Affairs each must include detailed unit-specific
786 performance standards, benchmarks, and metrics in the report,
787 including projected cost savings to the state Medicaid program
788 during the following fiscal year.
789 (1) For the purposes of this section, the term:
790 (a) “Abuse” means:
791 1. Provider practices that are inconsistent with generally
792 accepted business or medical practices and that result in an
793 unnecessary cost to the Medicaid program or in reimbursement for
794 goods or services that are not medically necessary or that fail
795 to meet professionally recognized standards for health care.
796 2. Recipient practices that result in unnecessary cost to
797 the Medicaid program.
798 (b) “Complaint” means an allegation that fraud, abuse, or
799 an overpayment has occurred.
800 (c) “Fraud” means an intentional deception or
801 misrepresentation made by a person with the knowledge that the
802 deception results in unauthorized benefit to herself or himself
803 or another person. The term includes any act that constitutes
804 fraud under applicable federal or state law.
805 (d) “Medical necessity” or “medically necessary” means any
806 goods or services necessary to palliate the effects of a
807 terminal condition, or to prevent, diagnose, correct, cure,
808 alleviate, or preclude deterioration of a condition that
809 threatens life, causes pain or suffering, or results in illness
810 or infirmity, which goods or services are provided in accordance
811 with generally accepted standards of medical practice. For
812 purposes of determining Medicaid reimbursement, the agency is
813 the final arbiter of medical necessity. Determinations of
814 medical necessity must be made by a licensed physician employed
815 by or under contract with the agency and must be based upon
816 information available at the time the goods or services are
817 provided.
818 (e) “Overpayment” includes any amount that is not
819 authorized to be paid by the Medicaid program whether paid as a
820 result of inaccurate or improper cost reporting, improper
821 claiming, unacceptable practices, fraud, abuse, or mistake.
822 (f) “Person” means any natural person, corporation,
823 partnership, association, clinic, group, or other entity,
824 whether or not such person is enrolled in the Medicaid program
825 or is a provider of health care.
826 (2) The agency shall conduct, or cause to be conducted by
827 contract or otherwise, reviews, investigations, analyses,
828 audits, or any combination thereof, to determine possible fraud,
829 abuse, overpayment, or recipient neglect in the Medicaid program
830 and shall report the findings of any overpayments in audit
831 reports as appropriate. At least 5 percent of all audits shall
832 be conducted on a random basis. As part of its ongoing fraud
833 detection activities, the agency shall identify and monitor, by
834 contract or otherwise, patterns of overutilization of Medicaid
835 services based on state averages. The agency shall track
836 Medicaid provider prescription and billing patterns and evaluate
837 them against Medicaid medical necessity criteria and coverage
838 and limitation guidelines adopted by rule. Medical necessity
839 determination requires that service be consistent with symptoms
840 or confirmed diagnosis of illness or injury under treatment and
841 not in excess of the patient’s needs. The agency shall conduct
842 reviews of provider exceptions to peer group norms and shall,
843 using statistical methodologies, provider profiling, and
844 analysis of billing patterns, detect and investigate abnormal or
845 unusual increases in billing or payment of claims for Medicaid
846 services and medically unnecessary provision of services.
847 (3) The agency may conduct, or may contract for, prepayment
848 review of provider claims to ensure cost-effective purchasing;
849 to ensure that billing by a provider to the agency is in
850 accordance with applicable provisions of all Medicaid rules,
851 regulations, handbooks, and policies and in accordance with
852 federal, state, and local law; and to ensure that appropriate
853 care is rendered to Medicaid recipients. Such prepayment reviews
854 may be conducted as determined appropriate by the agency,
855 without any suspicion or allegation of fraud, abuse, or neglect,
856 and may last for up to 1 year. Unless the agency has reliable
857 evidence of fraud, misrepresentation, abuse, or neglect, claims
858 shall be adjudicated for denial or payment within 90 days after
859 receipt of complete documentation by the agency for review. If
860 there is reliable evidence of fraud, misrepresentation, abuse,
861 or neglect, claims shall be adjudicated for denial of payment
862 within 180 days after receipt of complete documentation by the
863 agency for review.
864 (4) Any suspected criminal violation identified by the
865 agency must be referred to the Medicaid Fraud Control Unit of
866 the Office of the Attorney General for investigation. The agency
867 and the Attorney General shall enter into a memorandum of
868 understanding, which must include, but need not be limited to, a
869 protocol for regularly sharing information and coordinating
870 casework. The protocol must establish a procedure for the
871 referral by the agency of cases involving suspected Medicaid
872 fraud to the Medicaid Fraud Control Unit for investigation, and
873 the return to the agency of those cases where investigation
874 determines that administrative action by the agency is
875 appropriate. Offices of the Medicaid program integrity program
876 and the Medicaid Fraud Control Unit of the Department of Legal
877 Affairs, shall, to the extent possible, be collocated. The
878 agency and the Department of Legal Affairs shall periodically
879 conduct joint training and other joint activities designed to
880 increase communication and coordination in recovering
881 overpayments.
882 (5) A Medicaid provider is subject to having goods and
883 services that are paid for by the Medicaid program reviewed by
884 an appropriate peer-review organization designated by the
885 agency. The written findings of the applicable peer-review
886 organization are admissible in any court or administrative
887 proceeding as evidence of medical necessity or the lack thereof.
888 (6) Any notice required to be given to a provider under
889 this section is presumed to be sufficient notice if sent to the
890 address last shown on the provider enrollment file. It is the
891 responsibility of the provider to furnish and keep the agency
892 informed of the provider’s current address. United States Postal
893 Service proof of mailing or certified or registered mailing of
894 such notice to the provider at the address shown on the provider
895 enrollment file constitutes sufficient proof of notice. Any
896 notice required to be given to the agency by this section must
897 be sent to the agency at an address designated by rule.
898 (7) When presenting a claim for payment under the Medicaid
899 program, a provider has an affirmative duty to supervise the
900 provision of, and be responsible for, goods and services claimed
901 to have been provided, to supervise and be responsible for
902 preparation and submission of the claim, and to present a claim
903 that is true and accurate and that is for goods and services
904 that:
905 (a) Have actually been furnished to the recipient by the
906 provider prior to submitting the claim.
907 (b) Are Medicaid-covered goods or services that are
908 medically necessary.
909 (c) Are of a quality comparable to those furnished to the
910 general public by the provider’s peers.
911 (d) Have not been billed in whole or in part to a recipient
912 or a recipient’s responsible party, except for such copayments,
913 coinsurance, or deductibles as are authorized by the agency.
914 (e) Are provided in accord with applicable provisions of
915 all Medicaid rules, regulations, handbooks, and policies and in
916 accordance with federal, state, and local law.
917 (f) Are documented by records made at the time the goods or
918 services were provided, demonstrating the medical necessity for
919 the goods or services rendered. Medicaid goods or services are
920 excessive or not medically necessary unless both the medical
921 basis and the specific need for them are fully and properly
922 documented in the recipient’s medical record.
923
924 The agency shall deny payment or require repayment for goods or
925 services that are not presented as required in this subsection.
926 (8) The agency shall not reimburse any person or entity for
927 any prescription for medications, medical supplies, or medical
928 services if the prescription was written by a physician or other
929 prescribing practitioner who is not enrolled in the Medicaid
930 program. This section does not apply:
931 (a) In instances involving bona fide emergency medical
932 conditions as determined by the agency;
933 (b) To a provider of medical services to a patient in a
934 hospital emergency department, hospital inpatient or outpatient
935 setting, or nursing home;
936 (c) To bona fide pro bono services by preapproved non
937 Medicaid providers as determined by the agency;
938 (d) To prescribing physicians who are board-certified
939 specialists treating Medicaid recipients referred for treatment
940 by a treating physician who is enrolled in the Medicaid program;
941 (e) To prescriptions written for dually eligible Medicare
942 beneficiaries by an authorized Medicare provider who is not
943 enrolled in the Medicaid program;
944 (f) To other physicians who are not enrolled in the
945 Medicaid program but who provide a medically necessary service
946 or prescription not otherwise reasonably available from a
947 Medicaid-enrolled physician; or
948 (9) A Medicaid provider shall retain medical, professional,
949 financial, and business records pertaining to services and goods
950 furnished to a Medicaid recipient and billed to Medicaid for a
951 period of 6 5 years after the date of furnishing such services
952 or goods. The agency may investigate, review, or analyze such
953 records, which must be made available during normal business
954 hours. However, 24-hour notice must be provided if patient
955 treatment would be disrupted. The provider is responsible for
956 furnishing to the agency, and keeping the agency informed of the
957 location of, the provider’s Medicaid-related records. The
958 authority of the agency to obtain Medicaid-related records from
959 a provider is neither curtailed nor limited during a period of
960 litigation between the agency and the provider.
961 (10) Payments for the services of billing agents or persons
962 participating in the preparation of a Medicaid claim shall not
963 be based on amounts for which they bill nor based on the amount
964 a provider receives from the Medicaid program.
965 (11) The agency shall deny payment or require repayment for
966 inappropriate, medically unnecessary, or excessive goods or
967 services from the person furnishing them, the person under whose
968 supervision they were furnished, or the person causing them to
969 be furnished.
970 (12) The complaint and all information obtained pursuant to
971 an investigation of a Medicaid provider, or the authorized
972 representative or agent of a provider, relating to an allegation
973 of fraud, abuse, or neglect are confidential and exempt from the
974 provisions of s. 119.07(1):
975 (a) Until the agency takes final agency action with respect
976 to the provider and requires repayment of any overpayment, or
977 imposes an administrative sanction;
978 (b) Until the Attorney General refers the case for criminal
979 prosecution;
980 (c) Until 10 days after the complaint is determined without
981 merit; or
982 (d) At all times if the complaint or information is
983 otherwise protected by law.
984 (13) The agency shall immediately terminate participation
985 of a Medicaid provider in the Medicaid program and may seek
986 civil remedies or impose other administrative sanctions against
987 a Medicaid provider, if the provider or any principal, officer,
988 director, agent, managing employee, or affiliated person of the
989 provider, or any partner or shareholder having an ownership
990 interest in the provider equal to 5 percent or greater, has
991 been:
992 (a) Convicted of a criminal offense related to the delivery
993 of any health care goods or services, including the performance
994 of management or administrative functions relating to the
995 delivery of health care goods or services;
996 (b) Convicted of a criminal offense under federal law or
997 the law of any state relating to the practice of the provider’s
998 profession; or
999 (c) Found by a court of competent jurisdiction to have
1000 neglected or physically abused a patient in connection with the
1001 delivery of health care goods or services.
1002
1003 If the agency determines a provider did not participate or
1004 acquiesce in an offense specified in paragraph (a), paragraph
1005 (b), or paragraph (c), termination will not be imposed. If the
1006 agency effects a termination under this subsection, the agency
1007 shall issue an immediate termination final order as provided in
1008 subsection (16) pursuant to s. 120.569(2)(n).
1009 (14) If the provider has been suspended or terminated from
1010 participation in the Medicaid program or the Medicare program by
1011 the Federal Government or any state, the agency must immediately
1012 suspend or terminate, as appropriate, the provider’s
1013 participation in this state’s Medicaid program for a period no
1014 less than that imposed by the Federal Government or any other
1015 state, and may not enroll such provider in this state’s Medicaid
1016 program while such foreign suspension or termination remains in
1017 effect. The agency shall also immediately suspend or terminate,
1018 as appropriate, a provider’s participation in this state’s
1019 Medicaid program if the provider participated or acquiesced in
1020 any action for which any principal, officer, director, agent,
1021 managing employee, or affiliated person of the provider, or any
1022 partner or shareholder having an ownership interest in the
1023 provider equal to 5 percent or greater, was suspended or
1024 terminated from participating in the Medicaid program or the
1025 Medicare program by the Federal Government or any state. This
1026 sanction is in addition to all other remedies provided by law.
1027 If the agency suspends or terminates a provider’s participation
1028 in the state’s Medicaid program under this subsection, the
1029 agency shall issue an immediate suspension or immediate
1030 termination order as provided in subsection (16).
1031 (15) The agency shall seek a remedy provided by law,
1032 including, but not limited to, any remedy provided in
1033 subsections (13) and (16) and s. 812.035, if:
1034 (a) The provider’s license has not been renewed, or has
1035 been revoked, suspended, or terminated, for cause, by the
1036 licensing agency of any state;
1037 (b) The provider has failed to make available or has
1038 refused access to Medicaid-related records to an auditor,
1039 investigator, or other authorized employee or agent of the
1040 agency, the Attorney General, a state attorney, or the Federal
1041 Government;
1042 (c) The provider has not furnished or has failed to make
1043 available such Medicaid-related records as the agency has found
1044 necessary to determine whether Medicaid payments are or were due
1045 and the amounts thereof;
1046 (d) The provider has failed to maintain medical records
1047 made at the time of service, or prior to service if prior
1048 authorization is required, demonstrating the necessity and
1049 appropriateness of the goods or services rendered;
1050 (e) The provider is not in compliance with provisions of
1051 Medicaid provider publications that have been adopted by
1052 reference as rules in the Florida Administrative Code; with
1053 provisions of state or federal laws, rules, or regulations; with
1054 provisions of the provider agreement between the agency and the
1055 provider; or with certifications found on claim forms or on
1056 transmittal forms for electronically submitted claims that are
1057 submitted by the provider or authorized representative, as such
1058 provisions apply to the Medicaid program;
1059 (f) The provider or person who ordered or prescribed the
1060 care, services, or supplies has furnished, or ordered the
1061 furnishing of, goods or services to a recipient which are
1062 inappropriate, unnecessary, excessive, or harmful to the
1063 recipient or are of inferior quality;
1064 (g) The provider has demonstrated a pattern of failure to
1065 provide goods or services that are medically necessary;
1066 (h) The provider or an authorized representative of the
1067 provider, or a person who ordered or prescribed the goods or
1068 services, has submitted or caused to be submitted false or a
1069 pattern of erroneous Medicaid claims;
1070 (i) The provider or an authorized representative of the
1071 provider, or a person who has ordered or prescribed the goods or
1072 services, has submitted or caused to be submitted a Medicaid
1073 provider enrollment application, a request for prior
1074 authorization for Medicaid services, a drug exception request,
1075 or a Medicaid cost report that contains materially false or
1076 incorrect information;
1077 (j) The provider or an authorized representative of the
1078 provider has collected from or billed a recipient or a
1079 recipient’s responsible party improperly for amounts that should
1080 not have been so collected or billed by reason of the provider’s
1081 billing the Medicaid program for the same service;
1082 (k) The provider or an authorized representative of the
1083 provider has included in a cost report costs that are not
1084 allowable under a Florida Title XIX reimbursement plan, after
1085 the provider or authorized representative had been advised in an
1086 audit exit conference or audit report that the costs were not
1087 allowable;
1088 (l) The provider is charged by information or indictment
1089 with fraudulent billing practices or an offense under subsection
1090 (13). The sanction applied for this reason is limited to
1091 suspension of the provider’s participation in the Medicaid
1092 program for the duration of the indictment unless the provider
1093 is found guilty pursuant to the information or indictment;
1094 (m) The provider or a person who has ordered or prescribed
1095 the goods or services is found liable for negligent practice
1096 resulting in death or injury to the provider’s patient;
1097 (n) The provider fails to demonstrate that it had available
1098 during a specific audit or review period sufficient quantities
1099 of goods, or sufficient time in the case of services, to support
1100 the provider’s billings to the Medicaid program;
1101 (o) The provider has failed to comply with the notice and
1102 reporting requirements of s. 409.907;
1103 (p) The agency has received reliable information of patient
1104 abuse or neglect or of any act prohibited by s. 409.920; or
1105 (q) The provider has failed to comply with an agreed-upon
1106 repayment schedule.
1107
1108 A provider is subject to sanctions for violations of this
1109 subsection as the result of actions or inactions of the
1110 provider, or actions or inactions of any principal, officer,
1111 director, agent, managing employee, or affiliated person of the
1112 provider, or any partner or shareholder having an ownership
1113 interest in the provider equal to 5 percent or greater, in which
1114 the provider participated or acquiesced. If the agency
1115 immediately suspends or immediately terminates a provider under
1116 this subsection, the agency shall issue an immediate suspension
1117 or immediate termination order as provided in subsection (16).
1118 (16) The agency shall impose any of the following sanctions
1119 or disincentives on a provider or a person for any of the acts
1120 described in subsection (15):
1121 (a) Suspension for a specific period of time of not more
1122 than 1 year. Suspension shall preclude participation in the
1123 Medicaid program, which includes any action that results in a
1124 claim for payment to the Medicaid program as a result of
1125 furnishing, supervising a person who is furnishing, or causing a
1126 person to furnish goods or services.
1127 (b) Termination for a specific period of time of from more
1128 than 1 year to 20 years. Termination shall preclude
1129 participation in the Medicaid program, which includes any action
1130 that results in a claim for payment to the Medicaid program as a
1131 result of furnishing, supervising a person who is furnishing, or
1132 causing a person to furnish goods or services.
1133 (c) Imposition of a fine of up to $5,000 for each
1134 violation. Each day that an ongoing violation continues, such as
1135 refusing to furnish Medicaid-related records or refusing access
1136 to records, is considered, for the purposes of this section, to
1137 be a separate violation. Each instance of improper billing of a
1138 Medicaid recipient; each instance of including an unallowable
1139 cost on a hospital or nursing home Medicaid cost report after
1140 the provider or authorized representative has been advised in an
1141 audit exit conference or previous audit report of the cost
1142 unallowability; each instance of furnishing a Medicaid recipient
1143 goods or professional services that are inappropriate or of
1144 inferior quality as determined by competent peer judgment; each
1145 instance of knowingly submitting a materially false or erroneous
1146 Medicaid provider enrollment application, request for prior
1147 authorization for Medicaid services, drug exception request, or
1148 cost report; each instance of inappropriate prescribing of drugs
1149 for a Medicaid recipient as determined by competent peer
1150 judgment; and each false or erroneous Medicaid claim leading to
1151 an overpayment to a provider is considered, for the purposes of
1152 this section, to be a separate violation.
1153 (d) Immediate suspension, if the agency has received
1154 information of patient abuse or neglect, or of any act
1155 prohibited by s. 409.920, or any conduct listed in subsection
1156 (13) or subsection (14). Upon suspension, the agency must issue
1157 an immediate suspension final order, which shall state that the
1158 agency has reasonable cause to believe that the provider,
1159 person, or entity named is engaging in or has engaged in patient
1160 abuse or neglect, any act prohibited by s. 409.920, or any
1161 conduct listed in subsection (13) or subsection (14). The order
1162 shall provide notice of administrative hearing rights under ss.
1163 120.569 and 120.57 and is effective immediately upon notice to
1164 the provider, person, or entity under s. 120.569(2)(n).
1165 (e) Immediate termination, if the agency has received
1166 information of a conviction based on patient abuse or neglect,
1167 any act prohibited by s. 409.920, or any conduct listed in
1168 subsection (13) or subsection (14). Upon termination, the agency
1169 must issue an immediate termination order, which shall state
1170 that the agency has reasonable cause to believe that the
1171 provider, person, or entity named has been convicted of patient
1172 abuse or neglect, any act prohibited by s. 409.920, or any
1173 conduct listed in subsection (13) or subsection (14). The
1174 termination order shall provide notice of administrative hearing
1175 rights under ss. 120.569 and 120.57 and is effective immediately
1176 upon notice to the provider, person, or entity.
1177 (f)(e) A fine, not to exceed $10,000, for a violation of
1178 paragraph (15)(i).
1179 (g)(f) Imposition of liens against provider assets,
1180 including, but not limited to, financial assets and real
1181 property, not to exceed the amount of fines or recoveries
1182 sought, upon entry of an order determining that such moneys are
1183 due or recoverable.
1184 (h)(g) Prepayment reviews of claims for a specified period
1185 of time.
1186 (i)(h) Comprehensive followup reviews of providers every 6
1187 months to ensure that they are billing Medicaid correctly.
1188 (j)(i) Corrective-action plans that would remain in effect
1189 for providers for up to 3 years and that would be monitored by
1190 the agency every 6 months while in effect.
1191 (k)(j) Other remedies as permitted by law to effect the
1192 recovery of a fine or overpayment.
1193
1194 The Secretary of Health Care Administration may make a
1195 determination that imposition of a sanction or disincentive is
1196 not in the best interest of the Medicaid program, in which case
1197 a sanction or disincentive shall not be imposed.
1198 (17) In determining the appropriate administrative sanction
1199 to be applied, or the duration of any suspension or termination,
1200 the agency shall consider:
1201 (a) The seriousness and extent of the violation or
1202 violations.
1203 (b) Any prior history of violations by the provider
1204 relating to the delivery of health care programs which resulted
1205 in either a criminal conviction or in administrative sanction or
1206 penalty.
1207 (c) Evidence of continued violation within the provider’s
1208 management control of Medicaid statutes, rules, regulations, or
1209 policies after written notification to the provider of improper
1210 practice or instance of violation.
1211 (d) The effect, if any, on the quality of medical care
1212 provided to Medicaid recipients as a result of the acts of the
1213 provider.
1214 (e) Any action by a licensing agency respecting the
1215 provider in any state in which the provider operates or has
1216 operated.
1217 (f) The apparent impact on access by recipients to Medicaid
1218 services if the provider is suspended or terminated, in the best
1219 judgment of the agency.
1220
1221 The agency shall document the basis for all sanctioning actions
1222 and recommendations.
1223 (18) The agency may take action to sanction, suspend, or
1224 terminate a particular provider working for a group provider,
1225 and may suspend or terminate Medicaid participation at a
1226 specific location, rather than or in addition to taking action
1227 against an entire group.
1228 (19) The agency shall establish a process for conducting
1229 followup reviews of a sampling of providers who have a history
1230 of overpayment under the Medicaid program. This process must
1231 consider the magnitude of previous fraud or abuse and the
1232 potential effect of continued fraud or abuse on Medicaid costs.
1233 (20) In making a determination of overpayment to a
1234 provider, the agency must use accepted and valid auditing,
1235 accounting, analytical, statistical, or peer-review methods, or
1236 combinations thereof. Appropriate statistical methods may
1237 include, but are not limited to, sampling and extension to the
1238 population, parametric and nonparametric statistics, tests of
1239 hypotheses, and other generally accepted statistical methods.
1240 Appropriate analytical methods may include, but are not limited
1241 to, reviews to determine variances between the quantities of
1242 products that a provider had on hand and available to be
1243 purveyed to Medicaid recipients during the review period and the
1244 quantities of the same products paid for by the Medicaid program
1245 for the same period, taking into appropriate consideration sales
1246 of the same products to non-Medicaid customers during the same
1247 period. In meeting its burden of proof in any administrative or
1248 court proceeding, the agency may introduce the results of such
1249 statistical methods as evidence of overpayment.
1250 (21) When making a determination that an overpayment has
1251 occurred, the agency shall prepare and issue an audit report to
1252 the provider showing the calculation of overpayments.
1253 (22) The audit report, supported by agency work papers,
1254 showing an overpayment to a provider constitutes evidence of the
1255 overpayment. A provider may not present or elicit testimony,
1256 either on direct examination or cross-examination in any court
1257 or administrative proceeding, regarding the purchase or
1258 acquisition by any means of drugs, goods, or supplies; sales or
1259 divestment by any means of drugs, goods, or supplies; or
1260 inventory of drugs, goods, or supplies, unless such acquisition,
1261 sales, divestment, or inventory is documented by written
1262 invoices, written inventory records, or other competent written
1263 documentary evidence maintained in the normal course of the
1264 provider’s business. Notwithstanding the applicable rules of
1265 discovery, all documentation that will be offered as evidence at
1266 an administrative hearing on a Medicaid overpayment must be
1267 exchanged by all parties at least 14 days before the
1268 administrative hearing or must be excluded from consideration.
1269 (23)(a) In an audit or investigation of a violation
1270 committed by a provider which is conducted pursuant to this
1271 section, the agency is entitled to recover all investigative,
1272 legal, and expert witness costs if the agency’s findings were
1273 not contested by the provider or, if contested, the agency
1274 ultimately prevailed.
1275 (b) The agency has the burden of documenting the costs,
1276 which include salaries and employee benefits and out-of-pocket
1277 expenses. The amount of costs that may be recovered must be
1278 reasonable in relation to the seriousness of the violation and
1279 must be set taking into consideration the financial resources,
1280 earning ability, and needs of the provider, who has the burden
1281 of demonstrating such factors.
1282 (c) The provider may pay the costs over a period to be
1283 determined by the agency if the agency determines that an
1284 extreme hardship would result to the provider from immediate
1285 full payment. Any default in payment of costs may be collected
1286 by any means authorized by law.
1287 (24) If the agency imposes an administrative sanction
1288 pursuant to subsection (13), subsection (14), or subsection
1289 (15), except paragraphs (15)(e) and (o), upon any provider or
1290 any principal, officer, director, agent, managing employee, or
1291 affiliated person of the provider who is regulated by another
1292 state entity, the agency shall notify that other entity of the
1293 imposition of the sanction within 5 business days. Such
1294 notification must include the provider’s or person’s name and
1295 license number and the specific reasons for sanction.
1296 (25)(a) The agency shall withhold Medicaid payments, in
1297 whole or in part, to a provider upon receipt of reliable
1298 evidence that the circumstances giving rise to the need for a
1299 withholding of payments involve fraud, willful
1300 misrepresentation, or abuse under the Medicaid program, or a
1301 crime committed while rendering goods or services to Medicaid
1302 recipients. If the provider is not paid within 14 days after the
1303 agency receives evidence it is determined that fraud, willful
1304 misrepresentation, abuse, or a crime did not occur, interest
1305 shall accrue at a rate of 10 percent a year the payments
1306 withheld must be paid to the provider within 14 days after such
1307 determination with interest at the rate of 10 percent a year.
1308 Any money withheld in accordance with this paragraph shall be
1309 placed in a suspended account, readily accessible to the agency,
1310 so that any payment ultimately due the provider shall be made
1311 within 14 days.
1312 (b) The agency shall deny payment, or require repayment, if
1313 the goods or services were furnished, supervised, or caused to
1314 be furnished by a person who has been convicted of a crime under
1315 subsection (13) or who has been suspended or terminated from the
1316 Medicaid program or Medicare program by the Federal Government
1317 or any state.
1318 (c) Overpayments owed to the agency bear interest at the
1319 rate of 10 percent per year from the date of determination of
1320 the overpayment by the agency, and payment arrangements for
1321 overpayments and fines must be made within 35 days after the
1322 date of the final order at the conclusion of legal proceedings.
1323 A provider who does not enter into or adhere to an agreed-upon
1324 repayment schedule may be terminated by the agency for
1325 nonpayment or partial payment.
1326 (d) The agency, upon entry of a final agency order, a
1327 judgment or order of a court of competent jurisdiction, or a
1328 stipulation or settlement, may collect the moneys owed by all
1329 means allowable by law, including, but not limited to, notifying
1330 any fiscal intermediary of Medicare benefits that the state has
1331 a superior right of payment. Upon receipt of such written
1332 notification, the Medicare fiscal intermediary shall remit to
1333 the state the sum claimed.
1334 (e) The agency may institute amnesty programs to allow
1335 Medicaid providers the opportunity to voluntarily repay
1336 overpayments. The agency may adopt rules to administer such
1337 programs.
1338 (26) The agency may impose administrative sanctions against
1339 a Medicaid recipient, or the agency may seek any other remedy
1340 provided by law, including, but not limited to, the remedies
1341 provided in s. 812.035, if the agency finds that a recipient has
1342 engaged in solicitation in violation of s. 409.920 or that the
1343 recipient has otherwise abused the Medicaid program.
1344 (27) When the Agency for Health Care Administration has
1345 made a probable cause determination and alleged that an
1346 overpayment to a Medicaid provider has occurred, the agency,
1347 after notice to the provider, shall:
1348 (a) Withhold, and continue to withhold during the pendency
1349 of an administrative hearing pursuant to chapter 120, any
1350 medical assistance reimbursement payments until such time as the
1351 overpayment is recovered, unless within 30 days after receiving
1352 notice thereof the provider:
1353 1. Makes repayment in full; or
1354 2. Establishes a repayment plan that is satisfactory to the
1355 Agency for Health Care Administration.
1356 (b) Withhold, and continue to withhold during the pendency
1357 of an administrative hearing pursuant to chapter 120, medical
1358 assistance reimbursement payments if the terms of a repayment
1359 plan are not adhered to by the provider.
1360 (28) Venue for all Medicaid program integrity overpayment
1361 cases shall lie in Leon County, at the discretion of the agency.
1362 (29) Notwithstanding other provisions of law, the agency
1363 and the Medicaid Fraud Control Unit of the Department of Legal
1364 Affairs may review a provider’s Medicaid-related and non
1365 Medicaid-related records in order to determine the total output
1366 of a provider’s practice to reconcile quantities of goods or
1367 services billed to Medicaid with quantities of goods or services
1368 used in the provider’s total practice.
1369 (30) The agency shall terminate a provider’s participation
1370 in the Medicaid program if the provider fails to reimburse an
1371 overpayment or fine that has been determined by final order, not
1372 subject to further appeal, within 35 days after the date of the
1373 final order, unless the provider and the agency have entered
1374 into a repayment agreement.
1375 (31) If a provider requests an administrative hearing
1376 pursuant to chapter 120, such hearing must be conducted within
1377 90 days following assignment of an administrative law judge,
1378 absent exceptionally good cause shown as determined by the
1379 administrative law judge or hearing officer. Upon issuance of a
1380 final order, the outstanding balance of the amount determined to
1381 constitute the overpayment or fine shall become due. If a
1382 provider fails to make payments in full, fails to enter into a
1383 satisfactory repayment plan, or fails to comply with the terms
1384 of a repayment plan or settlement agreement, the agency shall
1385 withhold medical assistance reimbursement payments until the
1386 amount due is paid in full.
1387 (32) Duly authorized agents and employees of the agency
1388 shall have the power to inspect, during normal business hours,
1389 the records of any pharmacy, wholesale establishment, or
1390 manufacturer, or any other place in which drugs and medical
1391 supplies are manufactured, packed, packaged, made, stored, sold,
1392 or kept for sale, for the purpose of verifying the amount of
1393 drugs and medical supplies ordered, delivered, or purchased by a
1394 provider. The agency shall provide at least 2 business days’
1395 prior notice of any such inspection. The notice must identify
1396 the provider whose records will be inspected, and the inspection
1397 shall include only records specifically related to that
1398 provider.
1399 (33) In accordance with federal law, Medicaid recipients
1400 convicted of a crime pursuant to 42 U.S.C. s. 1320a-7b may be
1401 limited, restricted, or suspended from Medicaid eligibility for
1402 a period not to exceed 1 year, as determined by the agency head
1403 or designee.
1404 (34) To deter fraud and abuse in the Medicaid program, the
1405 agency may limit the number of Schedule II and Schedule III
1406 refill prescription claims submitted from a pharmacy provider.
1407 The agency shall limit the allowable amount of reimbursement of
1408 prescription refill claims for Schedule II and Schedule III
1409 pharmaceuticals if the agency or the Medicaid Fraud Control Unit
1410 determines that the specific prescription refill was not
1411 requested by the Medicaid recipient or authorized representative
1412 for whom the refill claim is submitted or was not prescribed by
1413 the recipient’s medical provider or physician. Any such refill
1414 request must be consistent with the original prescription.
1415 (35) The Office of Program Policy Analysis and Government
1416 Accountability shall provide a report to the President of the
1417 Senate and the Speaker of the House of Representatives on a
1418 biennial basis, beginning January 31, 2006, on the agency’s and
1419 the Medicaid Fraud Control Unit’s efforts to prevent, detect,
1420 and deter, as well as recover funds lost to, fraud and abuse in
1421 the Medicaid program.
1422 (36) At least three times a year, the agency shall provide
1423 to each Medicaid recipient or his or her representative an
1424 explanation of benefits in the form of a letter that is mailed
1425 to the most recent address of the recipient on the record with
1426 the Department of Children and Family Services. The explanation
1427 of benefits must include the patient’s name, the name of the
1428 health care provider and the address of the location where the
1429 service was provided, a description of all services billed to
1430 Medicaid in terminology that should be understood by a
1431 reasonable person, and information on how to report
1432 inappropriate or incorrect billing to the agency or other law
1433 enforcement entities for review or investigation. At least once
1434 a year, the letter also must include information on how to
1435 report criminal Medicaid fraud, the Medicaid Fraud Control
1436 Unit’s toll-free hotline number, and information about the
1437 rewards available under s. 409.9203. The explanation of benefits
1438 may not be mailed for Medicaid independent laboratory services
1439 as described in s. 409.905(7) or for Medicaid certified match
1440 services as described in ss. 409.9071 and 1011.70.
1441 (37) The agency shall post on its website a current list of
1442 each Medicaid provider, including any principal, officer,
1443 director, agent, managing employee, or affiliated person of the
1444 provider, or any partner or shareholder having an ownership
1445 interest in the provider equal to 5 percent or greater, who has
1446 been terminated for cause from the Medicaid program or
1447 sanctioned under this section. The list must be searchable by a
1448 variety of search parameters and provide for the creation of
1449 formatted lists that may be printed or imported into other
1450 applications, including spreadsheets. The agency shall update
1451 the list at least monthly.
1452 (38) In order to improve the detection of health care
1453 fraud, use technology to prevent and detect fraud, and maximize
1454 the electronic exchange of health care fraud information, the
1455 agency shall:
1456 (a) Compile, maintain, and publish on its website a
1457 detailed list of all state and federal databases that contain
1458 health care fraud information and update the list at least
1459 biannually;
1460 (b) Develop a strategic plan to connect all databases that
1461 contain health care fraud information to facilitate the
1462 electronic exchange of health information between the agency,
1463 the Department of Health, the Department of Law Enforcement, and
1464 the Attorney General’s Office. The plan must include recommended
1465 standard data formats, fraud identification strategies, and
1466 specifications for the technical interface between state and
1467 federal health care fraud databases;
1468 (c) Monitor innovations in health information technology,
1469 specifically as it pertains to Medicaid fraud prevention and
1470 detection; and
1471 (d) Periodically publish policy briefs that highlight
1472 available new technology to prevent or detect health care fraud
1473 and projects implemented by other states, the private sector, or
1474 the Federal Government which use technology to prevent or detect
1475 health care fraud.
1476 Section 9. Subsection (5) is added to section 409.9203,
1477 Florida Statutes, to read:
1478 409.9203 Rewards for reporting Medicaid fraud.—
1479 (5) An employee of the Agency for Health Care
1480 Administration, the Department of Legal Affairs, the Department
1481 of Health, or the Department of Law Enforcement whose job
1482 responsibilities include the prevention, detection, and
1483 prosecution of Medicaid fraud is not eligible to receive a
1484 reward under this section.
1485 Section 10. Subsection (8) is added to section 456.001,
1486 Florida Statutes, to read:
1487 456.001 Definitions.—As used in this chapter, the term:
1488 (8) “Affiliate” or “affiliated person” means any person who
1489 directly or indirectly manages, controls, or oversees the
1490 operation of a corporation or other business entity, regardless
1491 of whether such person is a partner, shareholder, owner,
1492 officer, director, or agent of the entity.
1493 Section 11. Paragraph (c) of subsection (1) and subsections
1494 (2) and (3) of section 456.041, Florida Statutes, are amended to
1495 read:
1496 456.041 Practitioner profile; creation.—
1497 (1)
1498 (c) Within 30 calendar days after receiving an update of
1499 information required for the practitioner’s profile, the
1500 department shall update the practitioner’s profile in accordance
1501 with the requirements of subsection (8) (7).
1502 (2) Beginning July 1, 2010, on the profile published under
1503 subsection (1), the department shall include indicate if the
1504 information provided under s. 456.039(1)(a)7. or s.
1505 456.0391(1)(a)7. and indicate if the information is or is not
1506 corroborated by a criminal history records check conducted
1507 according to this subsection. The department must include in
1508 each practitioner’s profile the following statement: “The
1509 criminal history information, if any exists, may be incomplete.
1510 Federal criminal history information is not available to the
1511 public.” The department, or the board having regulatory
1512 authority over the practitioner acting on behalf of the
1513 department, shall investigate any information received by the
1514 department or the board.
1515 (3) Beginning July 1, 2010, the department shall include in
1516 each practitioner’s profile any open administrative complaint
1517 filed with the department against the practitioner in which
1518 probable cause has been found. The Department of Health shall
1519 include in each practitioner’s practitioner profile that
1520 criminal information that directly relates to the practitioner’s
1521 ability to competently practice his or her profession. The
1522 department must include in each practitioner’s practitioner
1523 profile the following statement: “The criminal history
1524 information, if any exists, may be incomplete; federal criminal
1525 history information is not available to the public.” The
1526 department shall provide in each practitioner profile, for every
1527 final disciplinary action taken against the practitioner, an
1528 easy-to-read narrative description that explains the
1529 administrative complaint filed against the practitioner and the
1530 final disciplinary action imposed on the practitioner. The
1531 department shall include a hyperlink to each final order listed
1532 in its website report of dispositions of recent disciplinary
1533 actions taken against practitioners.
1534 Section 12. Section 456.0635, Florida Statutes, is amended
1535 to read:
1536 456.0635 Health care Medicaid fraud; disqualification for
1537 license, certificate, or registration.—
1538 (1) Medicaid Fraud in the practice of a health care
1539 profession is prohibited.
1540 (2) Each board within the jurisdiction of the department,
1541 or the department if there is no board, shall refuse to admit a
1542 candidate to any examination and refuse to issue or renew a
1543 license, certificate, or registration to any applicant if the
1544 candidate or applicant or any principal, officer, agent,
1545 managing employee, or affiliated person of the applicant, has
1546 been:
1547 (a) Has been convicted of, or entered a plea of guilty or
1548 nolo contendere to, regardless of adjudication, a felony under
1549 chapter 409, chapter 817, chapter 893, or a similar felony
1550 offense committed in another state or jurisdiction 21 U.S.C. ss.
1551 801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and any
1552 subsequent period of probation for such conviction or plea pleas
1553 ended: more than 15 years prior to the date of the application;
1554 1. For felonies of the first or second degree more than 15
1555 years before the date of application.
1556 2. For felonies of the third degree more than 10 years
1557 before the date of application, except for felonies of the third
1558 degree under s. 893.13(6)(a).
1559 3. For felonies of the third degree under s. 893.13(6)(a),
1560 more than 5 years before the date of application.
1561 4. For felonies in which the defendant entered a plea of
1562 guilty or nolo contendere in an agreement with the court to
1563 enter a pretrial intervention or drug diversion program, the
1564 department shall not approve or deny the application for a
1565 license, certificate, or registration until the final resolution
1566 of the case.
1567 (b) Has been convicted of, or entered a plea of guilty or
1568 nolo contendere to, regardless of adjudication, a felony under
1569 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the
1570 sentence and any subsequent period of probation for such
1571 conviction or plea ended more than 15 years before the date of
1572 the application;
1573 (c)(b) Has been terminated for cause from the Florida
1574 Medicaid program pursuant to s. 409.913, unless the applicant
1575 has been in good standing with the Florida Medicaid program for
1576 the most recent 5 years;
1577 (d)(c) Has been terminated for cause, pursuant to the
1578 appeals procedures established by the state or Federal
1579 Government, from any other state Medicaid program or the federal
1580 Medicare program, unless the applicant has been in good standing
1581 with a state Medicaid program or the federal Medicare program
1582 for the most recent 5 years and the termination occurred at
1583 least 20 years before prior to the date of the application; or.
1584 (e) Is currently listed on the United States Department of
1585 Health and Human Services Office of Inspector General’s List of
1586 Excluded Individuals and Entities.
1587 (f) This subsection does not apply to applicants for
1588 initial licensure or certification who were enrolled in an
1589 educational or training program on or before July 1, 2009, which
1590 was recognized by a board or, if there is no board, recognized
1591 by the department, and who applied for licensure after July 1,
1592 2009.
1593 (3) Each board within the jurisdiction of the department,
1594 or the department if there is no board, shall refuse to renew a
1595 license, certificate, or registration of any applicant if the
1596 candidate or applicant or any principal, officer, agent,
1597 managing employee, or affiliated person of the applicant:
1598 (a) Has been convicted of, or entered a plea of guilty or
1599 nolo contendere to, regardless of adjudication, a felony under:
1600 chapter 409, chapter 817, chapter 893, or a similar felony
1601 offense committed in another state or jurisdiction since July 1,
1602 2009.
1603 (b) Has been convicted of, or entered a plea of guilty or
1604 nolo contendere to, regardless of adjudication, a felony under
1605 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396 since July 1,
1606 2009.
1607 (c) Has been terminated for cause from the Florida Medicaid
1608 program pursuant to s. 409.913, unless the applicant has been in
1609 good standing with the Florida Medicaid program for the most
1610 recent 5 years.
1611 (d) Has been terminated for cause, pursuant to the appeals
1612 procedures established by the state, from any other state
1613 Medicaid program, unless the applicant has been in good standing
1614 with a state Medicaid program for the most recent 5 years and
1615 the termination occurred at least 20 years before the date of
1616 the application.
1617 (e) Is currently listed on the United States Department of
1618 Health and Human Services Office of Inspector General’s List of
1619 Excluded Individuals and Entities.
1620 (f) For felonies in which the defendant entered a plea of
1621 guilty or nolo contendere in an agreement with the court to
1622 enter a pretrial intervention or drug diversion program, the
1623 department shall not approve or deny the application for a
1624 renewal of a license, certificate, or registration until the
1625 final resolution of the case.
1626 (4)(3) Licensed health care practitioners shall report
1627 allegations of Medicaid fraud to the department, regardless of
1628 the practice setting in which the alleged Medicaid fraud
1629 occurred.
1630 (5)(4) The acceptance by a licensing authority of a
1631 candidate’s relinquishment of a license which is offered in
1632 response to or anticipation of the filing of administrative
1633 charges alleging Medicaid fraud or similar charges constitutes
1634 the permanent revocation of the license.
1635 (6) The department shall adopt rules to administer the
1636 provisions of this section related to denial of licensure
1637 renewal.
1638 Section 13. Paragraph (kk) of subsection (1) of section
1639 456.072, Florida Statutes, is amended to read:
1640 456.072 Grounds for discipline; penalties; enforcement.—
1641 (1) The following acts shall constitute grounds for which
1642 the disciplinary actions specified in subsection (2) may be
1643 taken:
1644 (kk) Being terminated from the state Medicaid program
1645 pursuant to s. 409.913 or, any other state Medicaid program, or
1646 excluded from the federal Medicare program, unless eligibility
1647 to participate in the program from which the practitioner was
1648 terminated has been restored.
1649 Section 14. Subsection (13) of section 456.073, Florida
1650 Statutes, is amended to read:
1651 456.073 Disciplinary proceedings.—Disciplinary proceedings
1652 for each board shall be within the jurisdiction of the
1653 department.
1654 (13) Notwithstanding any provision of law to the contrary,
1655 an administrative complaint against a licensee shall be filed
1656 within 6 years after the time of the incident or occurrence
1657 giving rise to the complaint against the licensee. If such
1658 incident or occurrence involved fraud related to the Medicaid
1659 program, criminal actions, diversion of controlled substances,
1660 sexual misconduct, or impairment by the licensee, this
1661 subsection does not apply to bar initiation of an investigation
1662 or filing of an administrative complaint beyond the 6-year
1663 timeframe. In those cases covered by this subsection in which it
1664 can be shown that fraud, concealment, or intentional
1665 misrepresentation of fact prevented the discovery of the
1666 violation of law, the period of limitations is extended forward,
1667 but in no event to exceed 12 years after the time of the
1668 incident or occurrence.
1669 Section 15. Subsection (1) of section 456.074, Florida
1670 Statutes, is amended to read:
1671 456.074 Certain health care practitioners; immediate
1672 suspension of license.—
1673 (1) The department shall issue an emergency order
1674 suspending the license of any person licensed in a profession as
1675 defined in this chapter under chapter 458, chapter 459, chapter
1676 460, chapter 461, chapter 462, chapter 463, chapter 464, chapter
1677 465, chapter 466, or chapter 484 who pleads guilty to, is
1678 convicted or found guilty of, or who enters a plea of nolo
1679 contendere to, regardless of adjudication, to:
1680 (a) A felony under chapter 409, chapter 812, chapter 817,
1681 or chapter 893, chapter 895, chapter 896, or under 21 U.S.C. ss.
1682 801-970, or under 42 U.S.C. ss. 1395-1396; or
1683 (b) A misdemeanor or felony under 18 U.S.C. s. 669, ss.
1684 285-287, s. 371, s. 1001, s. 1035, s. 1341, s. 1343, s. 1347, s.
1685 1349, or s. 1518 or 42 U.S.C. ss. 1320a-7b, relating to the
1686 Medicaid program.
1687 Section 16. Paragraph (q) of subsection (2) of section
1688 499.01, Florida Statutes, is amended to read:
1689 499.01 Permits.—
1690 (2) The following permits are established:
1691 (q) Device manufacturer permit.—A device manufacturer
1692 permit is required for any person that engages in the
1693 manufacture, repackaging, or assembly of medical devices for
1694 human use in this state, except that a permit is not required
1695 if:
1696 1. The person does not manufacture, repackage, or assemble
1697 any medical devices or components for such devices, except those
1698 devices or components which are exempt from registration
1699 pursuant to s. 499.015(8); or
1700 2. The person is engaged only in manufacturing,
1701 repackaging, or assembling a medical device pursuant to a
1702 practitioner’s order for a specific patient.
1703 a.1. A manufacturer or repackager of medical devices in
1704 this state must comply with all appropriate state and federal
1705 good manufacturing practices and quality system rules.
1706 b.2. The department shall adopt rules related to storage,
1707 handling, and recordkeeping requirements for manufacturers of
1708 medical devices for human use.
1709 Section 17. This act shall take effect July 1, 2010.