Florida Senate - 2012 COMMITTEE AMENDMENT
Bill No. SB 1316
Barcode 830922
LEGISLATIVE ACTION
Senate . House
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The Committee on Health Regulation (Gaetz) recommended the
following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Subsection (6) of section 400.474, Florida
6 Statutes, is amended, present subsection (7) of that section is
7 renumbered as subsection (8), and a new subsection (7) is added
8 to that section, to read:
9 400.474 Administrative penalties.—
10 (6) The agency may deny, revoke, or suspend the license of
11 a home health agency and shall impose a fine of $5,000 against a
12 home health agency that:
13 (a) Gives remuneration for staffing services to:
14 1. Another home health agency with which it has formal or
15 informal patient-referral transactions or arrangements; or
16 2. A health services pool with which it has formal or
17 informal patient-referral transactions or arrangements,
18
19 unless the home health agency has activated its comprehensive
20 emergency management plan in accordance with s. 400.492. This
21 paragraph does not apply to a Medicare-certified home health
22 agency that provides fair market value remuneration for staffing
23 services to a non-Medicare-certified home health agency that is
24 part of a continuing care facility licensed under chapter 651
25 for providing services to its own residents if each resident
26 receiving home health services pursuant to this arrangement
27 attests in writing that he or she made a decision without
28 influence from staff of the facility to select, from a list of
29 Medicare-certified home health agencies provided by the
30 facility, that Medicare-certified home health agency to provide
31 the services.
32 (b) Provides services to residents in an assisted living
33 facility for which the home health agency does not receive fair
34 market value remuneration.
35 (c) Provides staffing to an assisted living facility for
36 which the home health agency does not receive fair market value
37 remuneration.
38 (d) Fails to provide the agency, upon request, with copies
39 of all contracts with assisted living facilities which were
40 executed within 5 years before the request.
41 (e) Gives remuneration to a case manager, discharge
42 planner, facility-based staff member, or third-party vendor who
43 is involved in the discharge planning process of a facility
44 licensed under chapter 395, chapter 429, or this chapter from
45 whom the home health agency receives referrals.
46 (f) Fails to submit to the agency, within 15 days after the
47 end of each calendar quarter, a written report that includes the
48 following data based on data as it existed on the last day of
49 the quarter:
50 1. The number of insulin-dependent diabetic patients
51 receiving insulin-injection services from the home health
52 agency;
53 2. The number of patients receiving both home health
54 services from the home health agency and hospice services;
55 3. The number of patients receiving home health services
56 from that home health agency; and
57 4. The names and license numbers of nurses whose primary
58 job responsibility is to provide home health services to
59 patients and who received remuneration from the home health
60 agency in excess of $25,000 during the calendar quarter.
61 (f)(g) Gives cash, or its equivalent, to a Medicare or
62 Medicaid beneficiary.
63 (g)(h) Has more than one medical director contract in
64 effect at one time or more than one medical director contract
65 and one contract with a physician-specialist whose services are
66 mandated for the home health agency in order to qualify to
67 participate in a federal or state health care program at one
68 time.
69 (h)(i) Gives remuneration to a physician without a medical
70 director contract being in effect. The contract must:
71 1. Be in writing and signed by both parties;
72 2. Provide for remuneration that is at fair market value
73 for an hourly rate, which must be supported by invoices
74 submitted by the medical director describing the work performed,
75 the dates on which that work was performed, and the duration of
76 that work; and
77 3. Be for a term of at least 1 year.
78
79 The hourly rate specified in the contract may not be increased
80 during the term of the contract. The home health agency may not
81 execute a subsequent contract with that physician which has an
82 increased hourly rate and covers any portion of the term that
83 was in the original contract.
84 (i)(j) Gives remuneration to:
85 1. A physician, and the home health agency is in violation
86 of paragraph (g) (h) or paragraph (h) (i);
87 2. A member of the physician’s office staff; or
88 3. An immediate family member of the physician,
89
90 if the home health agency has received a patient referral in the
91 preceding 12 months from that physician or physician’s office
92 staff.
93 (j)(k) Fails to provide to the agency, upon request, copies
94 of all contracts with a medical director which were executed
95 within 5 years before the request.
96 (k)(l) Demonstrates a pattern of billing the Medicaid
97 program for services to Medicaid recipients which are medically
98 unnecessary as determined by a final order. A pattern may be
99 demonstrated by a showing of at least two such medically
100 unnecessary services within one Medicaid program integrity audit
101 period.
102
103 Paragraphs (e) and (i) do not apply to or preclude Nothing in
104 paragraph (e) or paragraph (j) shall be interpreted as applying
105 to or precluding any discount, compensation, waiver of payment,
106 or payment practice permitted by 42 U.S.C. s. 1320a-7(b) or
107 regulations adopted thereunder, including 42 C.F.R. s. 1001.952
108 or s. 1395nn or regulations adopted thereunder.
109 (7) The agency shall impose a fine of $50 per day against a
110 home health agency that fails to submit to the agency, within 15
111 days after the end of each calendar quarter, a written report
112 that includes the following data based on data as it existed on
113 the last day of the quarter:
114 (a) The number of patients receiving both home health
115 services from the home health agency and hospice services;
116 (b) The number of patients receiving home health services
117 from the home health agency;
118 (c) The number of insulin-dependent diabetic patients
119 receiving insulin-injection services from the home health
120 agency; and
121 (d) The names and license numbers of nurses whose primary
122 job responsibility is to provide home health services to
123 patients and who received remuneration from the home health
124 agency in excess of $25,000 during the calendar quarter.
125 Section 2. Paragraph (l) of subsection (4) of section
126 400.9905, Florida Statutes, is amended, and paragraph (m) is
127 added to that subsection, to read:
128 400.9905 Definitions.—
129 (4) “Clinic” means an entity at which health care services
130 are provided to individuals and which tenders charges for
131 reimbursement for such services, including a mobile clinic and a
132 portable equipment provider. For purposes of this part, the term
133 does not include and the licensure requirements of this part do
134 not apply to:
135 (l) Orthotic, or prosthetic, pediatric cardiology, or
136 perinatology clinical facilities or anesthesia clinical
137 facilities that are not otherwise exempt under paragraph (a) or
138 paragraph (k) and that are a publicly traded corporation or that
139 are wholly owned, directly or indirectly, by a publicly traded
140 corporation. As used in this paragraph, a publicly traded
141 corporation is a corporation that issues securities traded on an
142 exchange registered with the United States Securities and
143 Exchange Commission as a national securities exchange.
144 (m) Entities that are owned or controlled, directly or
145 indirectly, by a publicly traded entity that has $100 million or
146 more, in the aggregate, in total annual revenues derived from
147 providing health care services by licensed health care
148 practitioners who are employed or contracted by an entity
149 described in this paragraph.
150 Section 3. Paragraph (i) of subsection (4) of section
151 409.221, Florida Statutes, is amended to read:
152 409.221 Consumer-directed care program.—
153 (4) CONSUMER-DIRECTED CARE.—
154 (i) Background screening requirements.—All persons who
155 render care under this section must undergo level 2 background
156 screening pursuant to chapter 435 and s. 408.809. The agency
157 shall, as allowable, reimburse consumer-employed caregivers for
158 the cost of conducting such background screening as required by
159 this section. For purposes of this section, a person who has
160 undergone screening, who is qualified for employment under this
161 section and applicable rule, and who has not been unemployed for
162 more than 90 days following such screening is not required to be
163 rescreened. Such person must attest under penalty of perjury to
164 not having been convicted of a disqualifying offense since
165 completing such screening.
166 Section 4. Paragraph (c) of subsection (3) of section
167 409.907, Florida Statutes, is amended, paragraph (k) is added to
168 that subsection, and subsections (6), (7), and (8) of that
169 section are amended, to read:
170 409.907 Medicaid provider agreements.—The agency may make
171 payments for medical assistance and related services rendered to
172 Medicaid recipients only to an individual or entity who has a
173 provider agreement in effect with the agency, who is performing
174 services or supplying goods in accordance with federal, state,
175 and local law, and who agrees that no person shall, on the
176 grounds of handicap, race, color, or national origin, or for any
177 other reason, be subjected to discrimination under any program
178 or activity for which the provider receives payment from the
179 agency.
180 (3) The provider agreement developed by the agency, in
181 addition to the requirements specified in subsections (1) and
182 (2), shall require the provider to:
183 (c) Retain all medical and Medicaid-related records for 6 a
184 period of 5 years to satisfy all necessary inquiries by the
185 agency.
186 (k) Report a change in any principal of the provider,
187 including any officer, director, agent, managing employee, or
188 affiliated person, or any partner or shareholder who has an
189 ownership interest equal to 5 percent or more in the provider,
190 to the agency in writing no later than 30 days after the change
191 occurs.
192 (6) A Medicaid provider agreement may be revoked, at the
193 option of the agency, due to as the result of a change of
194 ownership of any facility, association, partnership, or other
195 entity named as the provider in the provider agreement.
196 (a) In the event of a change of ownership, the transferor
197 remains liable for all outstanding overpayments, administrative
198 fines, and any other moneys owed to the agency before the
199 effective date of the change of ownership. In addition to the
200 continuing liability of the transferor, The transferee is also
201 liable to the agency for all outstanding overpayments identified
202 by the agency on or before the effective date of the change of
203 ownership. For purposes of this subsection, the term
204 “outstanding overpayment” includes any amount identified in a
205 preliminary audit report issued to the transferor by the agency
206 on or before the effective date of the change of ownership. In
207 the event of a change of ownership for a skilled nursing
208 facility or intermediate care facility, the Medicaid provider
209 agreement shall be assigned to the transferee if the transferee
210 meets all other Medicaid provider qualifications. In the event
211 of a change of ownership involving a skilled nursing facility
212 licensed under part II of chapter 400, liability for all
213 outstanding overpayments, administrative fines, and any moneys
214 owed to the agency before the effective date of the change of
215 ownership shall be determined in accordance with s. 400.179.
216 (b) At least 60 days before the anticipated date of the
217 change of ownership, the transferor must shall notify the agency
218 of the intended change of ownership and the transferee must
219 shall submit to the agency a Medicaid provider enrollment
220 application. If a change of ownership occurs without compliance
221 with the notice requirements of this subsection, the transferor
222 and transferee are shall be jointly and severally liable for all
223 overpayments, administrative fines, and other moneys due to the
224 agency, regardless of whether the agency identified the
225 overpayments, administrative fines, or other moneys before or
226 after the effective date of the change of ownership. The agency
227 may not approve a transferee’s Medicaid provider enrollment
228 application if the transferee or transferor has not paid or
229 agreed in writing to a payment plan for all outstanding
230 overpayments, administrative fines, and other moneys due to the
231 agency. This subsection does not preclude the agency from
232 seeking any other legal or equitable remedies available to the
233 agency for the recovery of moneys owed to the Medicaid program.
234 In the event of a change of ownership involving a skilled
235 nursing facility licensed under part II of chapter 400,
236 liability for all outstanding overpayments, administrative
237 fines, and any moneys owed to the agency before the effective
238 date of the change of ownership shall be determined in
239 accordance with s. 400.179 if the Medicaid provider enrollment
240 application for change of ownership is submitted before the
241 change of ownership.
242 (c) As used in this subsection, the term:
243 1. “Administrative fines” includes any amount identified in
244 a notice of a monetary penalty or fine which has been issued by
245 the agency or other regulatory or licensing agency that governs
246 the provider.
247 2. “Outstanding overpayment” includes any amount identified
248 in a preliminary audit report issued to the transferor by the
249 agency on or before the effective date of a change of ownership.
250 (7) The agency may require, As a condition of participating
251 in the Medicaid program and before entering into the provider
252 agreement, the agency may require that the provider to submit
253 information, in an initial and any required renewal
254 applications, concerning the professional, business, and
255 personal background of the provider and permit an onsite
256 inspection of the provider’s service location by agency staff or
257 other personnel designated by the agency to perform this
258 function. Before entering into a provider agreement, the agency
259 may shall perform an a random onsite inspection, within 60 days
260 after receipt of a fully complete new provider’s application, of
261 the provider’s service location prior to making its first
262 payment to the provider for Medicaid services to determine the
263 applicant’s ability to provide the services in compliance with
264 the Medicaid program and professional regulations that the
265 applicant is proposing to provide for Medicaid reimbursement.
266 The agency is not required to perform an onsite inspection of a
267 provider or program that is licensed by the agency, that
268 provides services under waiver programs for home and community
269 based services, or that is licensed as a medical foster home by
270 the Department of Children and Family Services. As a continuing
271 condition of participation in the Medicaid program, a provider
272 must shall immediately notify the agency of any current or
273 pending bankruptcy filing. Before entering into the provider
274 agreement, or as a condition of continuing participation in the
275 Medicaid program, the agency may also require that Medicaid
276 providers reimbursed on a fee-for-services basis or fee schedule
277 basis that which is not cost-based, post a surety bond not to
278 exceed $50,000 or the total amount billed by the provider to the
279 program during the current or most recent calendar year,
280 whichever is greater. For new providers, the amount of the
281 surety bond shall be determined by the agency based on the
282 provider’s estimate of its first year’s billing. If the
283 provider’s billing during the first year exceeds the bond
284 amount, the agency may require the provider to acquire an
285 additional bond equal to the actual billing level of the
286 provider. A provider’s bond need shall not exceed $50,000 if a
287 physician or group of physicians licensed under chapter 458,
288 chapter 459, or chapter 460 has a 50 percent or greater
289 ownership interest in the provider or if the provider is an
290 assisted living facility licensed under chapter 429. The bonds
291 permitted by this section are in addition to the bonds
292 referenced in s. 400.179(2)(d). If the provider is a
293 corporation, partnership, association, or other entity, the
294 agency may require the provider to submit information concerning
295 the background of that entity and of any principal of the
296 entity, including any partner or shareholder having an ownership
297 interest in the entity equal to 5 percent or greater, and any
298 treating provider who participates in or intends to participate
299 in Medicaid through the entity. The information must include:
300 (a) Proof of holding a valid license or operating
301 certificate, as applicable, if required by the state or local
302 jurisdiction in which the provider is located or if required by
303 the Federal Government.
304 (b) Information concerning any prior violation, fine,
305 suspension, termination, or other administrative action taken
306 under the Medicaid laws, rules, or regulations of this state or
307 of any other state or the Federal Government; any prior
308 violation of the laws, rules, or regulations relating to the
309 Medicare program; any prior violation of the rules or
310 regulations of any other public or private insurer; and any
311 prior violation of the laws, rules, or regulations of any
312 regulatory body of this or any other state.
313 (c) Full and accurate disclosure of any financial or
314 ownership interest that the provider, or any principal, partner,
315 or major shareholder thereof, may hold in any other Medicaid
316 provider or health care related entity or any other entity that
317 is licensed by the state to provide health or residential care
318 and treatment to persons.
319 (d) If a group provider, identification of all members of
320 the group and attestation that all members of the group are
321 enrolled in or have applied to enroll in the Medicaid program.
322 (8)(a) Each provider, or each principal of the provider if
323 the provider is a corporation, partnership, association, or
324 other entity, seeking to participate in the Medicaid program
325 must submit a complete set of his or her fingerprints to the
326 agency for the purpose of conducting a criminal history record
327 check. Principals of the provider include any officer, director,
328 billing agent, managing employee, or affiliated person, or any
329 partner or shareholder who has an ownership interest equal to 5
330 percent or more in the provider. However, for a hospital
331 licensed under chapter 395 or a nursing home licensed under
332 chapter 400, principals of the provider are those who meet the
333 definition of a controlling interest under s. 408.803. A
334 director of a not-for-profit corporation or organization is not
335 a principal for purposes of a background investigation as
336 required by this section if the director: serves solely in a
337 voluntary capacity for the corporation or organization, does not
338 regularly take part in the day-to-day operational decisions of
339 the corporation or organization, receives no remuneration from
340 the not-for-profit corporation or organization for his or her
341 service on the board of directors, has no financial interest in
342 the not-for-profit corporation or organization, and has no
343 family members with a financial interest in the not-for-profit
344 corporation or organization; and if the director submits an
345 affidavit, under penalty of perjury, to this effect to the
346 agency and the not-for-profit corporation or organization
347 submits an affidavit, under penalty of perjury, to this effect
348 to the agency as part of the corporation’s or organization’s
349 Medicaid provider agreement application.
350 (a) Notwithstanding the above, the agency may require a
351 background check for any person reasonably suspected by the
352 agency to have been convicted of a crime. This subsection does
353 not apply to:
354 1. A hospital licensed under chapter 395;
355 2. A nursing home licensed under chapter 400;
356 3. A hospice licensed under chapter 400;
357 4. An assisted living facility licensed under chapter 429;
358 1.5. A unit of local government, except that requirements
359 of this subsection apply to nongovernmental providers and
360 entities contracting with the local government to provide
361 Medicaid services. The actual cost of the state and national
362 criminal history record checks must be borne by the
363 nongovernmental provider or entity; or
364 2.6. Any business that derives more than 50 percent of its
365 revenue from the sale of goods to the final consumer, and the
366 business or its controlling parent is required to file a form
367 10-K or other similar statement with the Securities and Exchange
368 Commission or has a net worth of $50 million or more.
369 (b) Background screening shall be conducted in accordance
370 with chapter 435 and s. 408.809. The cost of the state and
371 national criminal record check shall be borne by the provider.
372 (c) Proof of compliance with the requirements of level 2
373 screening under chapter 435 conducted within 12 months before
374 the date the Medicaid provider application is submitted to the
375 agency fulfills the requirements of this subsection.
376 Section 5. Present paragraphs (e) and (f) of subsection (1)
377 of section 409.913, Florida Statutes, are redesignated as
378 paragraphs (f) and (g), respectively, a new paragraph (e) is
379 added to that subsection, and subsections (2), (9), (13), (15),
380 (16), (21), (22), (25), (28), (29), (30), and (31) of that
381 section are amended, to read:
382 409.913 Oversight of the integrity of the Medicaid
383 program.—The agency shall operate a program to oversee the
384 activities of Florida Medicaid recipients, and providers and
385 their representatives, to ensure that fraudulent and abusive
386 behavior and neglect of recipients occur to the minimum extent
387 possible, and to recover overpayments and impose sanctions as
388 appropriate. Beginning January 1, 2003, and each year
389 thereafter, the agency and the Medicaid Fraud Control Unit of
390 the Department of Legal Affairs shall submit a joint report to
391 the Legislature documenting the effectiveness of the state’s
392 efforts to control Medicaid fraud and abuse and to recover
393 Medicaid overpayments during the previous fiscal year. The
394 report must describe the number of cases opened and investigated
395 each year; the sources of the cases opened; the disposition of
396 the cases closed each year; the amount of overpayments alleged
397 in preliminary and final audit letters; the number and amount of
398 fines or penalties imposed; any reductions in overpayment
399 amounts negotiated in settlement agreements or by other means;
400 the amount of final agency determinations of overpayments; the
401 amount deducted from federal claiming as a result of
402 overpayments; the amount of overpayments recovered each year;
403 the amount of cost of investigation recovered each year; the
404 average length of time to collect from the time the case was
405 opened until the overpayment is paid in full; the amount
406 determined as uncollectible and the portion of the uncollectible
407 amount subsequently reclaimed from the Federal Government; the
408 number of providers, by type, that are terminated from
409 participation in the Medicaid program as a result of fraud and
410 abuse; and all costs associated with discovering and prosecuting
411 cases of Medicaid overpayments and making recoveries in such
412 cases. The report must also document actions taken to prevent
413 overpayments and the number of providers prevented from
414 enrolling in or reenrolling in the Medicaid program as a result
415 of documented Medicaid fraud and abuse and must include policy
416 recommendations necessary to prevent or recover overpayments and
417 changes necessary to prevent and detect Medicaid fraud. All
418 policy recommendations in the report must include a detailed
419 fiscal analysis, including, but not limited to, implementation
420 costs, estimated savings to the Medicaid program, and the return
421 on investment. The agency must submit the policy recommendations
422 and fiscal analyses in the report to the appropriate estimating
423 conference, pursuant to s. 216.137, by February 15 of each year.
424 The agency and the Medicaid Fraud Control Unit of the Department
425 of Legal Affairs each must include detailed unit-specific
426 performance standards, benchmarks, and metrics in the report,
427 including projected cost savings to the state Medicaid program
428 during the following fiscal year.
429 (1) For the purposes of this section, the term:
430 (e) “Medicaid provider” or “provider” has the same meaning
431 as provided in s. 409.901 and, for purposes of oversight of the
432 integrity of the Medicaid program, also includes a participant
433 in a Medicaid managed care provider network.
434 (2) The agency shall conduct, or cause to be conducted by
435 contract or otherwise, reviews, investigations, analyses,
436 audits, or any combination thereof, to determine possible fraud,
437 abuse, overpayment, or recipient neglect in the Medicaid program
438 and shall report the findings of any overpayments in audit
439 reports as appropriate. At least 5 percent of all audits must
440 shall be conducted on a random basis. As part of its ongoing
441 fraud detection activities, the agency shall identify and
442 monitor, by contract or otherwise, patterns of overutilization
443 of Medicaid services based on state averages. The agency shall
444 track Medicaid provider prescription and billing patterns and
445 evaluate them against Medicaid medical necessity criteria and
446 coverage and limitation guidelines adopted by rule. Medical
447 necessity determination requires that service be consistent with
448 symptoms or confirmed diagnosis of illness or injury under
449 treatment and not in excess of the patient’s needs. The agency
450 shall conduct reviews of provider exceptions to peer group norms
451 and shall, using statistical methodologies, provider profiling,
452 and analysis of billing patterns, detect and investigate
453 abnormal or unusual increases in billing or payment of claims
454 for Medicaid services and medically unnecessary provision of
455 services. The agency may review and analyze information from
456 sources other than enrolled Medicaid providers in conducting its
457 activities under this subsection.
458 (9) A Medicaid provider shall retain medical, professional,
459 financial, and business records pertaining to services and goods
460 furnished to a Medicaid recipient and billed to Medicaid for 6 a
461 period of 5 years after the date of furnishing such services or
462 goods. The agency may investigate, review, or analyze such
463 records, which must be made available during normal business
464 hours. However, 24-hour notice must be provided if patient
465 treatment would be disrupted. The provider is responsible for
466 furnishing to the agency, and keeping the agency informed of the
467 location of, the provider’s Medicaid-related records. The
468 authority of the agency to obtain Medicaid-related records from
469 a provider is neither curtailed nor limited during a period of
470 litigation between the agency and the provider.
471 (13) The agency shall immediately terminate participation
472 of a Medicaid provider in the Medicaid program and may seek
473 civil remedies or impose other administrative sanctions against
474 a Medicaid provider, if the provider or any principal, officer,
475 director, agent, managing employee, or affiliated person of the
476 provider, or any partner or shareholder having an ownership
477 interest in the provider equal to 5 percent or greater, has been
478 convicted of a criminal offense under federal law or the law of
479 any state relating to the practice of the provider’s profession,
480 or an offense listed under s. 409.907(10), s. 408.809(4), or s.
481 435.04(2) has been:
482 (a) Convicted of a criminal offense related to the delivery
483 of any health care goods or services, including the performance
484 of management or administrative functions relating to the
485 delivery of health care goods or services;
486 (b) Convicted of a criminal offense under federal law or
487 the law of any state relating to the practice of the provider’s
488 profession; or
489 (c) Found by a court of competent jurisdiction to have
490 neglected or physically abused a patient in connection with the
491 delivery of health care goods or services. If the agency
492 determines that the a provider did not participate or acquiesce
493 in the an offense specified in paragraph (a), paragraph (b), or
494 paragraph (c), termination will not be imposed. If the agency
495 effects a termination under this subsection, the agency shall
496 issue an immediate final order pursuant to s. 120.569(2)(n).
497 (15) The agency shall seek a remedy provided by law,
498 including, but not limited to, any remedy provided in
499 subsections (13) and (16) and s. 812.035, if:
500 (a) The provider’s license has not been renewed, or has
501 been revoked, suspended, or terminated, for cause, by the
502 licensing agency of any state;
503 (b) The provider has failed to make available or has
504 refused access to Medicaid-related records to an auditor,
505 investigator, or other authorized employee or agent of the
506 agency, the Attorney General, a state attorney, or the Federal
507 Government;
508 (c) The provider has not furnished or has failed to make
509 available such Medicaid-related records as the agency has found
510 necessary to determine whether Medicaid payments are or were due
511 and the amounts thereof;
512 (d) The provider has failed to maintain medical records
513 made at the time of service, or prior to service if prior
514 authorization is required, demonstrating the necessity and
515 appropriateness of the goods or services rendered;
516 (e) The provider is not in compliance with provisions of
517 Medicaid provider publications that have been adopted by
518 reference as rules in the Florida Administrative Code; with
519 provisions of state or federal laws, rules, or regulations; with
520 provisions of the provider agreement between the agency and the
521 provider; or with certifications found on claim forms or on
522 transmittal forms for electronically submitted claims that are
523 submitted by the provider or authorized representative, as such
524 provisions apply to the Medicaid program;
525 (f) The provider or person who ordered, authorized, or
526 prescribed the care, services, or supplies has furnished, or
527 ordered, or authorized the furnishing of, goods or services to a
528 recipient which are inappropriate, unnecessary, excessive, or
529 harmful to the recipient or are of inferior quality;
530 (g) The provider has demonstrated a pattern of failure to
531 provide goods or services that are medically necessary;
532 (h) The provider or an authorized representative of the
533 provider, or a person who ordered, authorized, or prescribed the
534 goods or services, has submitted or caused to be submitted false
535 or a pattern of erroneous Medicaid claims;
536 (i) The provider or an authorized representative of the
537 provider, or a person who has ordered, authorized, or prescribed
538 the goods or services, has submitted or caused to be submitted a
539 Medicaid provider enrollment application, a request for prior
540 authorization for Medicaid services, a drug exception request,
541 or a Medicaid cost report that contains materially false or
542 incorrect information;
543 (j) The provider or an authorized representative of the
544 provider has collected from or billed a recipient or a
545 recipient’s responsible party improperly for amounts that should
546 not have been so collected or billed by reason of the provider’s
547 billing the Medicaid program for the same service;
548 (k) The provider or an authorized representative of the
549 provider has included in a cost report costs that are not
550 allowable under a Florida Title XIX reimbursement plan, after
551 the provider or authorized representative had been advised in an
552 audit exit conference or audit report that the costs were not
553 allowable;
554 (l) The provider is charged by information or indictment
555 with fraudulent billing practices or any offense referenced in
556 subsection (13). The sanction applied for this reason is limited
557 to suspension of the provider’s participation in the Medicaid
558 program for the duration of the indictment unless the provider
559 is found guilty pursuant to the information or indictment;
560 (m) The provider or a person who has ordered, authorized,
561 or prescribed the goods or services is found liable for
562 negligent practice resulting in death or injury to the
563 provider’s patient;
564 (n) The provider fails to demonstrate that it had available
565 during a specific audit or review period sufficient quantities
566 of goods, or sufficient time in the case of services, to support
567 the provider’s billings to the Medicaid program;
568 (o) The provider has failed to comply with the notice and
569 reporting requirements of s. 409.907;
570 (p) The agency has received reliable information of patient
571 abuse or neglect or of any act prohibited by s. 409.920; or
572 (q) The provider has failed to comply with an agreed-upon
573 repayment schedule.
574
575 A provider is subject to sanctions for violations of this
576 subsection as the result of actions or inactions of the
577 provider, or actions or inactions of any principal, officer,
578 director, agent, managing employee, or affiliated person of the
579 provider, or any partner or shareholder having an ownership
580 interest in the provider equal to 5 percent or greater, in which
581 the provider participated or acquiesced.
582 (16) The agency shall impose any of the following sanctions
583 or disincentives on a provider or a person for any of the acts
584 described in subsection (15):
585 (a) Suspension for a specific period of time of not more
586 than 1 year. Suspension precludes shall preclude participation
587 in the Medicaid program, which includes any action that results
588 in a claim for payment to the Medicaid program as a result of
589 furnishing, supervising a person who is furnishing, or causing a
590 person to furnish goods or services.
591 (b) Termination for a specific period of time of from more
592 than 1 year to 20 years. Termination precludes shall preclude
593 participation in the Medicaid program, which includes any action
594 that results in a claim for payment to the Medicaid program as a
595 result of furnishing, supervising a person who is furnishing, or
596 causing a person to furnish goods or services.
597 (c) Imposition of a fine of up to $5,000 for each
598 violation. Each day that an ongoing violation continues, such as
599 refusing to furnish Medicaid-related records or refusing access
600 to records, is considered, for the purposes of this section, to
601 be a separate violation. Each instance of improper billing of a
602 Medicaid recipient; each instance of including an unallowable
603 cost on a hospital or nursing home Medicaid cost report after
604 the provider or authorized representative has been advised in an
605 audit exit conference or previous audit report of the cost
606 unallowability; each instance of furnishing a Medicaid recipient
607 goods or professional services that are inappropriate or of
608 inferior quality as determined by competent peer judgment; each
609 instance of knowingly submitting a materially false or erroneous
610 Medicaid provider enrollment application, request for prior
611 authorization for Medicaid services, drug exception request, or
612 cost report; each instance of inappropriate prescribing of drugs
613 for a Medicaid recipient as determined by competent peer
614 judgment; and each false or erroneous Medicaid claim leading to
615 an overpayment to a provider is considered, for the purposes of
616 this section, to be a separate violation.
617 (d) Immediate suspension, if the agency has received
618 information of patient abuse or neglect or of any act prohibited
619 by s. 409.920. Upon suspension, the agency must issue an
620 immediate final order under s. 120.569(2)(n).
621 (e) A fine, not to exceed $10,000, for a violation of
622 paragraph (15)(i).
623 (f) Imposition of liens against provider assets, including,
624 but not limited to, financial assets and real property, not to
625 exceed the amount of fines or recoveries sought, upon entry of
626 an order determining that such moneys are due or recoverable.
627 (g) Prepayment reviews of claims for a specified period of
628 time.
629 (h) Comprehensive followup reviews of providers every 6
630 months to ensure that they are billing Medicaid correctly.
631 (i) Corrective-action plans that would remain in effect for
632 providers for up to 3 years and that are would be monitored by
633 the agency every 6 months while in effect.
634 (j) Other remedies as permitted by law to effect the
635 recovery of a fine or overpayment.
636
637 If a provider voluntarily relinquishes its Medicaid provider
638 number after receiving written notice that the agency is
639 conducting, or has conducted, an audit or investigation and the
640 sanction of suspension or termination will be imposed for
641 noncompliance discovered as a result of the audit or
642 investigation, the agency shall impose the sanction of
643 termination for cause against the provider. The Secretary of
644 Health Care Administration may make a determination that
645 imposition of a sanction or disincentive is not in the best
646 interest of the Medicaid program, in which case a sanction or
647 disincentive may shall not be imposed.
648 (21) When making a determination that an overpayment has
649 occurred, the agency shall prepare and issue an audit report to
650 the provider showing the calculation of overpayments. The
651 agency’s determination shall be based solely upon information
652 available to it before issuance of the audit report and, in the
653 case of documentation obtained to substantiate claims for
654 Medicaid reimbursement, based solely upon contemporaneous
655 records.
656 (22) The audit report, supported by agency work papers,
657 showing an overpayment to a provider constitutes evidence of the
658 overpayment. A provider may not present or elicit testimony,
659 either on direct examination or cross-examination in any court
660 or administrative proceeding, regarding the purchase or
661 acquisition by any means of drugs, goods, or supplies; sales or
662 divestment by any means of drugs, goods, or supplies; or
663 inventory of drugs, goods, or supplies, unless such acquisition,
664 sales, divestment, or inventory is documented by written
665 invoices, written inventory records, or other competent written
666 documentary evidence maintained in the normal course of the
667 provider’s business. Testimony or evidence that is not based
668 upon contemporaneous records or that was not furnished to the
669 agency within 21 days after the issuance of the audit report is
670 inadmissible in an administrative hearing on a Medicaid
671 overpayment or an administrative sanction. Notwithstanding the
672 applicable rules of discovery, all documentation to that will be
673 offered as evidence at an administrative hearing on a Medicaid
674 overpayment or an administrative sanction must be exchanged by
675 all parties at least 14 days before the administrative hearing
676 or must be excluded from consideration.
677 (25)(a) The agency shall withhold Medicaid payments, in
678 whole or in part, to a provider upon receipt of reliable
679 evidence that the circumstances giving rise to the need for a
680 withholding of payments involve fraud, willful
681 misrepresentation, or abuse under the Medicaid program, or a
682 crime committed while rendering goods or services to Medicaid
683 recipients. If it is determined that fraud, willful
684 misrepresentation, abuse, or a crime did not occur, the payments
685 withheld must be paid to the provider within 14 days after such
686 determination with interest at the rate of 10 percent a year.
687 Any money withheld in accordance with this paragraph shall be
688 placed in a suspended account, readily accessible to the agency,
689 so that any payment ultimately due the provider shall be made
690 within 14 days.
691 (b) The agency shall deny payment, or require repayment, if
692 the goods or services were furnished, supervised, or caused to
693 be furnished by a person who has been suspended or terminated
694 from the Medicaid program or Medicare program by the Federal
695 Government or any state.
696 (c) Overpayments owed to the agency bear interest at the
697 rate of 10 percent per year from the date of determination of
698 the overpayment by the agency, and payment arrangements
699 regarding overpayments and fines must be made within 30 days
700 after the date of the final order and are not subject to further
701 appeal at the conclusion of legal proceedings. A provider who
702 does not enter into or adhere to an agreed-upon repayment
703 schedule may be terminated by the agency for nonpayment or
704 partial payment.
705 (d) The agency, upon entry of a final agency order, a
706 judgment or order of a court of competent jurisdiction, or a
707 stipulation or settlement, may collect the moneys owed by all
708 means allowable by law, including, but not limited to, notifying
709 any fiscal intermediary of Medicare benefits that the state has
710 a superior right of payment. Upon receipt of such written
711 notification, the Medicare fiscal intermediary shall remit to
712 the state the sum claimed.
713 (e) The agency may institute amnesty programs to allow
714 Medicaid providers the opportunity to voluntarily repay
715 overpayments. The agency may adopt rules to administer such
716 programs.
717 (28) Venue for all Medicaid program integrity overpayment
718 cases lies shall lie in Leon County, at the discretion of the
719 agency.
720 (29) Notwithstanding other provisions of law, the agency
721 and the Medicaid Fraud Control Unit of the Department of Legal
722 Affairs may review a person’s or provider’s Medicaid-related and
723 non-Medicaid-related records in order to determine the total
724 output of a provider’s practice to reconcile quantities of goods
725 or services billed to Medicaid with quantities of goods or
726 services used in the provider’s total practice.
727 (30) The agency shall terminate a provider’s participation
728 in the Medicaid program if the provider fails to reimburse an
729 overpayment or pay a fine that has been determined by final
730 order, not subject to further appeal, within 30 35 days after
731 the date of the final order, unless the provider and the agency
732 have entered into a repayment agreement.
733 (31) If a provider requests an administrative hearing
734 pursuant to chapter 120, such hearing must be conducted within
735 90 days following assignment of an administrative law judge,
736 absent exceptionally good cause shown as determined by the
737 administrative law judge or hearing officer. Upon issuance of a
738 final order, the outstanding balance of the amount determined to
739 constitute the overpayment and fines is shall become due. If a
740 provider fails to make payments in full, fails to enter into a
741 satisfactory repayment plan, or fails to comply with the terms
742 of a repayment plan or settlement agreement, the agency shall
743 withhold medical assistance reimbursement payments for Medicaid
744 services until the amount due is paid in full.
745 Section 6. Subsection (8) of section 409.920, Florida
746 Statutes, is amended to read:
747 409.920 Medicaid provider fraud.—
748 (8) A person who provides the state, any state agency, any
749 of the state’s political subdivisions, or any agency of the
750 state’s political subdivisions with information about fraud or
751 suspected fraudulent acts fraud by a Medicaid provider,
752 including a managed care organization, is immune from civil
753 liability for libel, slander, or any other relevant tort for
754 providing any the information about fraud or suspected
755 fraudulent acts, unless the person acted with knowledge that the
756 information was false or with reckless disregard for the truth
757 or falsity of the information. For purposes of this subsection,
758 the term “fraudulent acts” includes actual or suspected fraud,
759 abuse, or overpayment, including any fraud-related matters that
760 a provider or health plan is required to report to the agency or
761 a law enforcement agency. The immunity from civil liability
762 extends to reports of fraudulent acts conveyed to the agency in
763 any manner, including any forum and with any audience as
764 directed by the agency, and includes all discussions subsequent
765 to the report and subsequent inquiries from the agency, unless
766 the person acted with knowledge that the information was false
767 or with reckless disregard for the truth or falsity of the
768 information.
769 Section 7. Paragraph (c) of subsection (2) of section
770 409.967, Florida Statutes, is amended to read:
771 409.967 Managed care plan accountability.—
772 (2) The agency shall establish such contract requirements
773 as are necessary for the operation of the statewide managed care
774 program. In addition to any other provisions the agency may deem
775 necessary, the contract must require:
776 (c) Access.—
777 1. Providers.—The agency shall establish specific standards
778 for the number, type, and regional distribution of providers in
779 managed care plan networks to ensure access to care for both
780 adults and children. Each plan must maintain a regionwide
781 network of providers in sufficient numbers to meet the access
782 standards for specific medical services for all recipients
783 enrolled in the plan. The exclusive use of mail-order pharmacies
784 is may not be sufficient to meet network access standards.
785 Consistent with the standards established by the agency,
786 provider networks may include providers located outside the
787 region. A plan may contract with a new hospital facility before
788 the date the hospital becomes operational if the hospital has
789 commenced construction, will be licensed and operational by
790 January 1, 2013, and a final order has issued in any civil or
791 administrative challenge. Each plan shall establish and maintain
792 an accurate and complete electronic database of contracted
793 providers, including information about licensure or
794 registration, locations and hours of operation, specialty
795 credentials and other certifications, specific performance
796 indicators, and such other information as the agency deems
797 necessary. The database must be available online to both the
798 agency and the public and have the capability to compare the
799 availability of providers to network adequacy standards and to
800 accept and display feedback from each provider’s patients. Each
801 plan shall submit quarterly reports to the agency identifying
802 the number of enrollees assigned to each primary care provider.
803 2. Prescribed drugs.—
804 a. If establishing a prescribed drug formulary or preferred
805 drug list, a managed care plan must:
806 (I) Provide coverage for drugs in categories and classes
807 for all disease states and provide a broad range of therapeutic
808 options for all therapeutic categories;
809 (II) Include coverage for each drug newly approved by the
810 federal Food and Drug Administration until the plan’s
811 Pharmaceutical and Therapeutics Committee reviews such drug for
812 inclusion on the formulary;
813 (III) Provide a response within 24 hours after receipt of
814 all necessary information for a request for prior authorization
815 or override of other medical management tools; and
816 (IV) Report all denials to the agency on a quarterly basis.
817 For each nonformulary drug, the plan must report the total
818 number of requests and the total number of denials.
819 b. Each managed care plan shall must publish any prescribed
820 drug formulary or preferred drug list on the plan’s website in a
821 manner that is accessible to and searchable by enrollees and
822 providers. The plan must update the list within 24 hours after
823 making a change. Each plan must ensure that the prior
824 authorization process for prescribed drugs is readily accessible
825 to health care providers, including posting appropriate contact
826 information on its website and providing timely responses to
827 providers.
828 c. The managed care plan must continue to permit an
829 enrollee who was receiving a prescription drug that was on the
830 plan’s formulary and subsequently removed or changed to continue
831 to receive that drug if requested by the enrollee and prescriber
832 for as long as the enrollee is a member of the plan.
833 d. A managed care plan that imposes a step-therapy or a
834 fail-first protocol must do so in accordance with the following:
835 (I) If prescribed drugs for the treatment of a medical
836 condition are restricted for use by the plan through a step
837 therapy or fail-first protocol, the plan must provide the
838 prescriber with access to a clear and convenient process to
839 expeditiously request an override of such restriction from the
840 plan.
841 (II) An override of the restriction must be expeditiously
842 granted by the plan if the prescriber can demonstrate to the
843 plan that the preferred treatment required under the step
844 therapy or fail-first protocol:
845 (A) Has been ineffective in the treatment of the enrollee’s
846 disease or medical condition;
847 (B) Is reasonably expected to be ineffective based on the
848 known relevant physical or mental characteristics and medical
849 history of the enrollee and known characteristics of the drug
850 regimen; or
851 (C) Will cause or will likely cause an adverse reaction or
852 other physical harm to the enrollee.
853 (III) The maximum duration of a step-therapy or fail-first
854 protocol requirement may not be longer than the customary period
855 for the prescribed drug if such treatment is demonstrated by the
856 prescriber to be clinically ineffective. If the plan can
857 demonstrate, through sound clinical evidence, that the
858 originally prescribed drug is likely to require more than the
859 customary period for such drug to provide any relief or
860 amelioration to the enrollee, the step-therapy or fail-first
861 protocol may be extended, but no longer than the original
862 customary period for the drug, after which time the prescriber
863 may deem such treatment as clinically ineffective for the
864 enrollee. Once the prescriber deems the treatment to be
865 clinically ineffective, the plan must dispense and cover the
866 originally prescribed drug recommended by the prescriber.
867 e. For enrollees Medicaid recipients diagnosed with
868 hemophilia who have been prescribed anti-hemophilic-factor
869 replacement products, the agency shall provide for those
870 products and hemophilia overlay services through the agency’s
871 hemophilia disease management program.
872 3. Prior authorization.—
873 a. Each managed care plan must ensure that the prior
874 authorization process for prescribed drugs is readily accessible
875 to health care providers, including posting appropriate contact
876 information on its website and providing timely responses to
877 providers.
878 b. If a drug, determined to be medically necessary and
879 prescribed for an enrollee by a physician using sound clinical
880 judgment, is subject to prior authorization, the managed care
881 plan must provide payment to the pharmacist for dispensing such
882 drug without seeking prior authorization if the pharmacist
883 confirms that:
884 (I) The prescription is a refill or renewal of the same
885 drug for the same enrollee written by the same prescriber; or
886 (II) If the drug is generally prescribed for an indication
887 that is treated on an ongoing basis by continuous medication or
888 as-needed, the enrollee for whom the drug is prescribed has
889 filled a prescription for the same drug within the preceding 30
890 to 90 days.
891 c. If a prescribed drug requires prior authorization, the
892 managed care plan shall reimburse the pharmacist for dispensing
893 a 72-hour supply to the enrollee and process the prior
894 authorization request and send a response to the requesting
895 pharmacist within 24 hours after receiving the pharmacist’s
896 request for prior authorization.
897 d.3. Managed care plans, and their fiscal agents or
898 intermediaries, must accept prior authorization requests for any
899 service electronically.
900 Section 8. Subsection (11) is added to section 429.23,
901 Florida Statutes, to read:
902 429.23 Internal risk management and quality assurance
903 program; adverse incidents and reporting requirements.—
904 (11) The agency shall annually submit a report to the
905 Legislature on adverse incident reports by assisted living
906 facilities. The report must include the following information
907 arranged by county:
908 (a) A total number of adverse incidents;
909 (b) A listing, by category, of the type of adverse
910 incidents occurring within each category and the type of staff
911 involved;
912 (c) A listing, by category, of the types of injuries, if
913 any, and the number of injuries occurring within each category;
914 (d) Types of liability claims filed based on an adverse
915 incident report or reportable injury; and
916 (e) Disciplinary action taken against staff, categorized by
917 the type of staff involved.
918 Section 9. Present subsections (9), (10), and (11) of
919 section 429.26, Florida Statutes, are renumbered as subsections
920 (12), (13), and (14), respectively, and new subsections (9),
921 (10), and (11) are added to that section, to read:
922 429.26 Appropriateness of placements; examinations of
923 residents.—
924 (9) If, at any time after admission to a facility, agency
925 personnel question whether a resident needs care beyond that
926 which the facility is licensed to provide, the agency may
927 require the resident to be physically examined by a licensed
928 physician, licensed physician assistant, or certified nurse
929 practitioner. To the extent possible, the examination must be
930 performed by the resident’s preferred physician, physician
931 assistant, or nurse practitioner and paid for by the resident
932 with personal funds, except as provided in s. 429.18(2). This
933 subsection does not preclude the agency from imposing sanctions
934 for violations of subsection (1).
935 (a) Following examination, the examining physician,
936 physician assistant, or nurse practitioner shall complete and
937 sign a medical form provided by the agency. The completed
938 medical form must be submitted to the agency within 30 days
939 after the date the facility owner or administrator was notified
940 by the agency that a physical examination is required.
941 (b) A medical review team designated by the agency shall
942 determine whether the resident is appropriately residing in the
943 facility based on the completed medical form and, if necessary,
944 consultation with the physician, physician assistant, or nurse
945 practitioner who performed the examination. Members of the
946 medical review team making the determination may not include the
947 agency personnel who initially questioned the appropriateness of
948 the resident’s placement. The medical review team shall base its
949 decision on a comprehensive review of the resident’s physical
950 and functional status. A determination that the resident’s
951 placement is not appropriate is final and binding upon the
952 facility and the resident.
953 (c) A resident who is determined by the medical review team
954 to be inappropriately residing in a facility shall be given 30
955 days’ written notice to relocate by the owner or administrator,
956 unless the resident’s continued residence in the facility
957 presents an imminent danger to the health, safety, or welfare of
958 the resident or a substantial probability exists that death or
959 serious physical harm to the resident would result if the
960 resident is allowed to remain in the facility.
961 (10) If a mental health resident appears to have needs in
962 addition to those identified in the community living support
963 plan, the agency may require an evaluation by a mental health
964 professional, as determined by the Department of Children and
965 Family Services.
966 (11) A facility may not be required to retain a resident
967 who requires more services or care than the facility is able to
968 provide in accordance with its policies and criteria for
969 admission and continued residency.
970 Section 10. Effective July 1, 2012, section 456.0635,
971 Florida Statutes, is amended to read:
972 456.0635 Health care Medicaid fraud; disqualification for
973 license, certificate, or registration.—
974 (1) Health care Medicaid fraud in the practice of a health
975 care profession is prohibited.
976 (2) Each board under within the jurisdiction of the
977 department, or the department if there is no board, shall refuse
978 to admit a candidate to an any examination and refuse to issue
979 or renew a license, certificate, or registration to an any
980 applicant if the candidate or applicant or any principal,
981 officer, agent, managing employee, or affiliated person of the
982 applicant, has been:
983 (a) Has been convicted of, or entered a plea of guilty or
984 nolo contendere to, regardless of adjudication, a felony under
985 chapter 409, chapter 817, or chapter 893, or a similar felony
986 offense committed in another state or jurisdiction, unless the
987 candidate or applicant has successfully completed a drug court
988 program for that felony and provides proof that the plea has
989 been withdrawn or the charges have been dismissed. Any such
990 conviction or plea shall exclude the applicant or candidate from
991 licensure, examination, certification, or registration 21 U.S.C.
992 ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and
993 any subsequent period of probation for such conviction or plea
994 pleas ended: more than 15 years prior to the date of the
995 application;
996 1. For felonies of the first or second degree, more than 15
997 years before the date of application.
998 2. For felonies of the third degree, more than 10 years
999 before the date of application, except for felonies of the third
1000 degree under s. 893.13(6)(a).
1001 3. For felonies of the third degree under s. 893.13(6)(a),
1002 more than 5 years before the date of application.
1003 (b) Has been convicted of, or entered a plea of guilty or
1004 nolo contendere to, regardless of adjudication, a felony under
1005 21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396, unless the
1006 sentence and any subsequent period of probation for such
1007 conviction or plea ended more than 15 years before the date of
1008 the application.
1009 (c)(b) Has been terminated for cause from the Florida
1010 Medicaid program pursuant to s. 409.913, unless the candidate or
1011 applicant has been in good standing with the Florida Medicaid
1012 program for the most recent 5 years.;
1013 (d)(c) Has been terminated for cause, pursuant to the
1014 appeals procedures established by the state or Federal
1015 Government, from any other state Medicaid program or the federal
1016 Medicare program, unless the candidate or applicant has been in
1017 good standing with that a state Medicaid program or the federal
1018 Medicare program for the most recent 5 years and the termination
1019 occurred at least 20 years before prior to the date of the
1020 application.
1021 (e) Is currently listed on the United States Department of
1022 Health and Human Services Office of Inspector General’s List of
1023 Excluded Individuals and Entities.
1024
1025 This subsection does not apply to candidates or applicants for
1026 initial licensure or certification who were enrolled in an
1027 educational or training program on or before July 1, 2009, which
1028 was recognized by a board or, if there is no board, recognized
1029 by the department, and who applied for licensure after July 1,
1030 2012.
1031 (3) The department shall refuse to renew a license,
1032 certificate, or registration of any applicant if the applicant
1033 or any principal, officer, agent, managing employee, or
1034 affiliated person of the applicant:
1035 (a) Has been convicted of, or entered a plea of guilty or
1036 nolo contendere to, regardless of adjudication, a felony under
1037 chapter 409, chapter 817, or chapter 893, or a similar felony
1038 offense committed in another state or jurisdiction, unless the
1039 applicant is currently enrolled in a drug court program that
1040 allows the withdrawal of the plea for that felony upon
1041 successful completion of that program. Any such conviction or
1042 plea excludes the applicant or candidate from licensure,
1043 examination, certification, or registration unless the sentence
1044 and any subsequent period of probation for such conviction or
1045 plea ended:
1046 1. For felonies of the first or second degree, more than 15
1047 years before the date of application.
1048 2. For felonies of the third degree, more than 10 years
1049 before the date of application, except for felonies of the third
1050 degree under s. 893.13(6)(a).
1051 3. For felonies of the third degree under s. 893.13(6)(a),
1052 more than 5 years before the date of application.
1053 (b) Has been convicted of, or entered a plea of guilty or
1054 nolo contendere to, regardless of adjudication, a felony under
1055 21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396 since July 1,
1056 2009, unless the sentence and any subsequent period of probation
1057 for such conviction or plea ended more than 15 years before the
1058 date of the application.
1059 (c) Has been terminated for cause from the Florida Medicaid
1060 program pursuant to s. 409.913, unless the applicant has been in
1061 good standing with the Florida Medicaid program for the most
1062 recent 5 years.
1063 (d) Has been terminated for cause, pursuant to the appeals
1064 procedures established by the state, from any other state
1065 Medicaid program, unless the applicant has been in good standing
1066 with that state Medicaid program for the most recent 5 years and
1067 the termination occurred at least 20 years before the date of
1068 the application.
1069 (e) Is currently listed on the United States Department of
1070 Health and Human Services Office of Inspector General’s List of
1071 Excluded Individuals and Entities.
1072 (4)(3) Licensed health care practitioners shall report
1073 allegations of health care Medicaid fraud to the department,
1074 regardless of the practice setting in which the alleged health
1075 care Medicaid fraud occurred.
1076 (5)(4) The acceptance by a licensing authority of a
1077 licensee’s candidate’s relinquishment of a license which is
1078 offered in response to or anticipation of the filing of
1079 administrative charges alleging health care Medicaid fraud or
1080 similar charges constitutes the permanent revocation of the
1081 license.
1082 Section 11. Effective July 1, 2012, present subsections
1083 (14) and (15) of section 456.036, Florida Statutes, are
1084 renumbered as subsections (15) and (16), respectively, and a new
1085 subsection (14) is added to that section, to read:
1086 456.036 Licenses; active and inactive status; delinquency.—
1087 (14) A person who has been denied license renewal,
1088 certification, or registration under s. 456.0635(3) may regain
1089 licensure, certification, or registration only by meeting the
1090 qualifications and completing the application process for
1091 initial licensure as defined by the board, or the department if
1092 there is no board. However, a person who was denied renewal of
1093 licensure, certification, or registration under s. 24 of chapter
1094 2009-223, Laws of Florida, between July 1, 2009, and June 30,
1095 2012, is not required to retake and pass examinations applicable
1096 for initial licensure, certification, or registration.
1097 Section 12. Subsection (1) of section 456.074, Florida
1098 Statutes, is amended to read:
1099 456.074 Certain health care practitioners; immediate
1100 suspension of license.—
1101 (1) The department shall issue an emergency order
1102 suspending the license of any person licensed under chapter 458,
1103 chapter 459, chapter 460, chapter 461, chapter 462, chapter 463,
1104 chapter 464, chapter 465, chapter 466, or chapter 484 who pleads
1105 guilty to, is convicted or found guilty of, or who enters a plea
1106 of nolo contendere to, regardless of adjudication, to:
1107 (a) A felony under chapter 409, chapter 817, or chapter 893
1108 or under 21 U.S.C. ss. 801-970 or under 42 U.S.C. ss. 1395-1396;
1109 or
1110 (b) A misdemeanor or felony under 18 U.S.C. s. 669, ss.
1111 285-287, s. 371, s. 1001, s. 1035, s. 1341, s. 1343, s. 1347, s.
1112 1349, or s. 1518 or 42 U.S.C. ss. 1320a-7b, relating to the
1113 Medicaid program.
1114 Section 13. Paragraph (a) of subsection (54) of section
1115 499.003, Florida Statutes, is amended to read:
1116 499.003 Definitions of terms used in this part.—As used in
1117 this part, the term:
1118 (54) “Wholesale distribution” means distribution of
1119 prescription drugs to persons other than a consumer or patient,
1120 but does not include:
1121 (a) Any of the following activities, which is not a
1122 violation of s. 499.005(21) if such activity is conducted in
1123 accordance with s. 499.01(2)(g):
1124 1. The purchase or other acquisition by a hospital or other
1125 health care entity that is a member of a group purchasing
1126 organization of a prescription drug for its own use from the
1127 group purchasing organization or from other hospitals or health
1128 care entities that are members of that organization.
1129 2. The sale, purchase, or trade of a prescription drug or
1130 an offer to sell, purchase, or trade a prescription drug by a
1131 charitable organization described in s. 501(c)(3) of the
1132 Internal Revenue Code of 1986, as amended and revised, to a
1133 nonprofit affiliate of the organization to the extent otherwise
1134 permitted by law.
1135 3. The sale, purchase, or trade of a prescription drug or
1136 an offer to sell, purchase, or trade a prescription drug among
1137 hospitals or other health care entities that are under common
1138 control. For purposes of this subparagraph, “common control”
1139 means the power to direct or cause the direction of the
1140 management and policies of a person or an organization, whether
1141 by ownership of stock, by voting rights, by contract, or
1142 otherwise.
1143 4. The sale, purchase, trade, or other transfer of a
1144 prescription drug from or for any federal, state, or local
1145 government agency or any entity eligible to purchase
1146 prescription drugs at public health services prices pursuant to
1147 Pub. L. No. 102-585, s. 602 to a contract provider or its
1148 subcontractor for eligible patients of the agency or entity
1149 under the following conditions:
1150 a. The agency or entity must obtain written authorization
1151 for the sale, purchase, trade, or other transfer of a
1152 prescription drug under this subparagraph from the State Surgeon
1153 General or his or her designee.
1154 b. The contract provider or subcontractor must be
1155 authorized by law to administer or dispense prescription drugs.
1156 c. In the case of a subcontractor, the agency or entity
1157 must be a party to and execute the subcontract.
1158 d. A contract provider or subcontractor must maintain
1159 separate and apart from other prescription drug inventory any
1160 prescription drugs of the agency or entity in its possession.
1161 d.e. The contract provider and subcontractor must maintain
1162 and produce immediately for inspection all records of movement
1163 or transfer of all the prescription drugs belonging to the
1164 agency or entity, including, but not limited to, the records of
1165 receipt and disposition of prescription drugs. Each contractor
1166 and subcontractor dispensing or administering these drugs must
1167 maintain and produce records documenting the dispensing or
1168 administration. Records that are required to be maintained
1169 include, but are not limited to, a perpetual inventory itemizing
1170 drugs received and drugs dispensed by prescription number or
1171 administered by patient identifier, which must be submitted to
1172 the agency or entity quarterly.
1173 e.f. The contract provider or subcontractor may administer
1174 or dispense the prescription drugs only to the eligible patients
1175 of the agency or entity or must return the prescription drugs
1176 for or to the agency or entity. The contract provider or
1177 subcontractor must require proof from each person seeking to
1178 fill a prescription or obtain treatment that the person is an
1179 eligible patient of the agency or entity and must, at a minimum,
1180 maintain a copy of this proof as part of the records of the
1181 contractor or subcontractor required under sub-subparagraph e.
1182 f.g. In addition to the departmental inspection authority
1183 set forth in s. 499.051, the establishment of the contract
1184 provider and subcontractor and all records pertaining to
1185 prescription drugs subject to this subparagraph shall be subject
1186 to inspection by the agency or entity. All records relating to
1187 prescription drugs of a manufacturer under this subparagraph
1188 shall be subject to audit by the manufacturer of those drugs,
1189 without identifying individual patient information.
1190 Section 14. The Agency for Health Care Administration shall
1191 prepare a report within 18 months after the implementation of an
1192 expansion of managed care to new populations or the provision of
1193 new items and services. The agency shall post a draft of the
1194 report on its website and provide an opportunity for public
1195 comment. The final report shall be submitted to the Legislature,
1196 along with a description of the process for public input. The
1197 report must include an assessment of:
1198 (1) The impact of managed care on patient access to care,
1199 including an evaluation of any new barriers to the use of
1200 services and prescription drugs, created by the use of medical
1201 management or cost-containment tools.
1202 (2) The impact of the increased managed care expansion on
1203 the utilization of services, quality of care, and patient
1204 outcomes.
1205 (3) The use of prior authorization and other utilization
1206 management tools, including an assessment of whether these tools
1207 pose an undue administrative burden for health care providers or
1208 create barriers to needed care.
1209 Section 15. Except as otherwise expressly provided in this
1210 act, this act shall take effect upon becoming a law.
1211
1212 ================= T I T L E A M E N D M E N T ================
1213 And the title is amended as follows:
1214 Delete everything before the enacting clause
1215 and insert:
1216 A bill to be entitled
1217 An act relating to health care; amending s. 400.474,
1218 F.S.; revising the fine that may be imposed against a
1219 home health agency for failing to timely submit
1220 certain information to the Agency for Health Care
1221 Administration; amending s. 400.9905, F.S.; revising
1222 the definition of the term “clinic” as it relates to
1223 the Health Care Clinic Act; amending s. 409.221, F.S.;
1224 revising the background screening requirements for
1225 persons rendering care in the consumer-directed care
1226 program administered by the Agency for Health Care
1227 Administration; amending s. 409.907, F.S.; extending
1228 the records-retention period for certain Medicaid
1229 provider records; revising the provider agreement to
1230 require Medicaid providers to report changes in any
1231 principal of the provider to the agency; defining the
1232 term “administrative fines” for purposes of revoking a
1233 Medicaid provider agreement due to changes of
1234 ownership; authorizing, rather than requiring, an
1235 onsite inspection of a Medicaid provider’s service
1236 location before entering into a provider agreement;
1237 specifying the principals of a hospital or nursing
1238 home provider for the purposes of submitting
1239 fingerprints for background screening; removing
1240 certain providers from being subject to agency
1241 background checks; amending s. 409.913, F.S.; defining
1242 the term “Medicaid provider” or “provider” for
1243 purposes of oversight of the integrity of the Medicaid
1244 program; authorizing the agency to review and analyze
1245 information from sources other than Medicaid-enrolled
1246 providers for purposes of determining fraud, abuse,
1247 overpayment, or neglect; extending the records
1248 retention period for certain Medicaid provider
1249 records; revising the grounds for terminating a
1250 provider from the Medicaid program; requiring the
1251 agency to base its overpayment audit reports on
1252 certain information; deleting a requirement that the
1253 agency pay interest on certain withheld Medicaid
1254 payments; requiring payment arrangements for
1255 overpayments and fines to be made within a certain
1256 time; specifying that the venue for all Medicaid
1257 program integrity cases lies in Leon County;
1258 authorizing the agency and the Medicaid Fraud Control
1259 Unit to review certain records; amending s. 409.920,
1260 F.S.; clarifying the applicability of immunity from
1261 civil liability extended to persons who provide
1262 information about fraud or suspected fraudulent acts
1263 by a Medicaid provider; amending s. 409.967, F.S.;
1264 specifying required components of a Medicaid managed
1265 care plan relating to the provisions of medications;
1266 amending s. 429.23, F.S.; requiring the agency to
1267 submit a report to the Legislature on adverse incident
1268 reports from assisted living facilities; amending s.
1269 429.26, F.S.; authorizing the agency to require a
1270 resident of an assisted living facility to undergo a
1271 physical examination if the agency questions the
1272 appropriateness of the resident’s placement in that
1273 facility; authorizing release of the results of the
1274 examination to a medical review team to be used along
1275 with additional information to determine whether the
1276 resident’s placement in the assisted living facility
1277 is appropriate; providing for resident notification
1278 and relocation if the resident’s continued placement
1279 in the facility is not appropriate; authorizing the
1280 agency to require the evaluation of a mental health
1281 resident by a mental health professional; authorizing
1282 an assisted living facility to discharge a resident
1283 who requires more services or care than the facility
1284 is able to provide; amending s. 456.0635, F.S.;
1285 revising the grounds under which the Department of
1286 Health or corresponding board is required to refuse to
1287 admit a candidate to an examination and refuse to
1288 issue or renew a license, certificate, or registration
1289 of a health care practitioner; providing an exception;
1290 amending s. 456.036, F.S.; providing that all persons
1291 who were denied renewal of licensure, certification,
1292 or registration under s. 456.0635(3), F.S., may regain
1293 licensure, certification, or registration only by
1294 completing the application process for initial
1295 licensure; providing an exception; amending s.
1296 456.074, F.S.; revising the federal offenses for which
1297 the Department of Health must issue an emergency order
1298 suspending the license of certain health care
1299 professionals; amending s. 499.003, F.S.; removing a
1300 requirement that a contract provider or subcontractor
1301 maintain prescription drugs of the agency or entity in
1302 its possession separate and apart from other
1303 prescription drugs; requiring the Agency for Health
1304 Care Administration to prepare a report for public
1305 comment and submission to the Legislature following
1306 the expansion of services to new populations or of new
1307 services; providing effective dates.