Florida Senate - 2012 SB 1316
By Senator Gaetz
4-00891C-12 20121316__
1 A bill to be entitled
2 An act relating to health care; amending s. 400.474,
3 F.S.; revising the fine that may be imposed against a
4 home health agency for failing to timely submit
5 certain information to the Agency for Health Care
6 Administration; amending s. 409.221, F.S.; revising
7 the background screening requirements for persons
8 rendering care in the consumer-directed care program
9 administered by the Agency for Health Care
10 Administration; amending s. 409.907, F.S.; extending
11 the records-retention period for certain Medicaid
12 provider records; revising the provider agreement to
13 require Medicaid providers to report changes in any
14 principal of the provider to the agency; defining the
15 term “administrative fines” for purposes of revoking a
16 Medicaid provider agreement due to changes of
17 ownership; authorizing, rather than requiring, an
18 onsite inspection of a Medicaid provider’s service
19 location before entering into a provider agreement;
20 specifying the principals of a hospital or nursing
21 home provider for the purposes of submitting
22 fingerprints for background screening; removing
23 certain providers from being subject to agency
24 background checks; amending s. 409.913, F.S.; defining
25 the term “Medicaid provider” or “provider” for
26 purposes of oversight of the integrity of the Medicaid
27 program; authorizing the agency to review and analyze
28 information from sources other than Medicaid-enrolled
29 providers for purposes of determining fraud, abuse,
30 overpayment, or neglect; extending the records
31 retention period for certain Medicaid provider
32 records; revising the grounds for terminating a
33 provider from the Medicaid program; requiring the
34 agency to base its overpayment audit reports on
35 certain information; deleting a requirement that the
36 agency pay interest on certain withheld Medicaid
37 payments; requiring payment arrangements for
38 overpayments and fines to be made within a certain
39 time; specifying that the venue for all Medicaid
40 program integrity cases lies in Leon County;
41 authorizing the agency and the Medicaid Fraud Control
42 Unit to review certain records; amending s. 409.920,
43 F.S.; clarifying the applicability of immunity from
44 civil liability extended to persons who provide
45 information about fraud or suspected fraudulent acts
46 by a Medicaid provider; amending s. 409.967, F.S.;
47 specifying required components of a Medicaid managed
48 care plan relating to the provisions of medications;
49 amending s. 429.23, F.S.; requiring the agency to
50 submit a report to the Legislature on adverse incident
51 reports from assisted living facilities; amending s.
52 429.26, F.S.; authorizing the agency to require a
53 resident of an assisted living facility to undergo a
54 physical examination if the agency questions the
55 appropriateness of the resident’s placement in that
56 facility; authorizing release of the results of the
57 examination to a medical review team to be used along
58 with additional information to determine whether the
59 resident’s placement in the assisted living facility
60 is appropriate; providing for resident notification
61 and relocation if the resident’s continued placement
62 in the facility is not appropriate; authorizing the
63 agency to require the evaluation of a mental health
64 resident by a mental health professional; authorizing
65 an assisted living facility to discharge a resident
66 who requires more services or care than the facility
67 is able to provide; amending s. 456.0635, F.S.;
68 revising the grounds under which the Department of
69 Health or corresponding board is required to refuse to
70 admit a candidate to an examination and refuse to
71 issue or renew a license, certificate, or registration
72 of a health care practitioner; providing an exception;
73 amending s. 456.036, F.S.; providing that all persons
74 who were denied renewal of licensure, certification,
75 or registration under s. 456.0635(3), F.S., may regain
76 licensure, certification, or registration only by
77 completing the application process for initial
78 licensure; providing an exception; amending s.
79 456.074, F.S.; revising the federal offenses for which
80 the Department of Health must issue an emergency order
81 suspending the license of certain health care
82 professionals; requiring the agency to prepare a
83 report for public comment and submission to the
84 Legislature following the expansion of services to new
85 populations or of new services; providing effective
86 dates.
87
88 Be It Enacted by the Legislature of the State of Florida:
89
90 Section 1. Subsection (6) of section 400.474, Florida
91 Statutes, is amended, present subsection (7) of that section is
92 renumbered as subsection (8), and a new subsection (7) is added
93 to that section, to read:
94 400.474 Administrative penalties.—
95 (6) The agency may deny, revoke, or suspend the license of
96 a home health agency and shall impose a fine of $5,000 against a
97 home health agency that:
98 (a) Gives remuneration for staffing services to:
99 1. Another home health agency with which it has formal or
100 informal patient-referral transactions or arrangements; or
101 2. A health services pool with which it has formal or
102 informal patient-referral transactions or arrangements,
103
104 unless the home health agency has activated its comprehensive
105 emergency management plan in accordance with s. 400.492. This
106 paragraph does not apply to a Medicare-certified home health
107 agency that provides fair market value remuneration for staffing
108 services to a non-Medicare-certified home health agency that is
109 part of a continuing care facility licensed under chapter 651
110 for providing services to its own residents if each resident
111 receiving home health services pursuant to this arrangement
112 attests in writing that he or she made a decision without
113 influence from staff of the facility to select, from a list of
114 Medicare-certified home health agencies provided by the
115 facility, that Medicare-certified home health agency to provide
116 the services.
117 (b) Provides services to residents in an assisted living
118 facility for which the home health agency does not receive fair
119 market value remuneration.
120 (c) Provides staffing to an assisted living facility for
121 which the home health agency does not receive fair market value
122 remuneration.
123 (d) Fails to provide the agency, upon request, with copies
124 of all contracts with assisted living facilities which were
125 executed within 5 years before the request.
126 (e) Gives remuneration to a case manager, discharge
127 planner, facility-based staff member, or third-party vendor who
128 is involved in the discharge planning process of a facility
129 licensed under chapter 395, chapter 429, or this chapter from
130 whom the home health agency receives referrals.
131 (f) Fails to submit to the agency, within 15 days after the
132 end of each calendar quarter, a written report that includes the
133 following data based on data as it existed on the last day of
134 the quarter:
135 1. The number of insulin-dependent diabetic patients
136 receiving insulin-injection services from the home health
137 agency;
138 2. The number of patients receiving both home health
139 services from the home health agency and hospice services;
140 3. The number of patients receiving home health services
141 from that home health agency; and
142 4. The names and license numbers of nurses whose primary
143 job responsibility is to provide home health services to
144 patients and who received remuneration from the home health
145 agency in excess of $25,000 during the calendar quarter.
146 (f)(g) Gives cash, or its equivalent, to a Medicare or
147 Medicaid beneficiary.
148 (g)(h) Has more than one medical director contract in
149 effect at one time or more than one medical director contract
150 and one contract with a physician-specialist whose services are
151 mandated for the home health agency in order to qualify to
152 participate in a federal or state health care program at one
153 time.
154 (h)(i) Gives remuneration to a physician without a medical
155 director contract being in effect. The contract must:
156 1. Be in writing and signed by both parties;
157 2. Provide for remuneration that is at fair market value
158 for an hourly rate, which must be supported by invoices
159 submitted by the medical director describing the work performed,
160 the dates on which that work was performed, and the duration of
161 that work; and
162 3. Be for a term of at least 1 year.
163
164 The hourly rate specified in the contract may not be increased
165 during the term of the contract. The home health agency may not
166 execute a subsequent contract with that physician which has an
167 increased hourly rate and covers any portion of the term that
168 was in the original contract.
169 (i)(j) Gives remuneration to:
170 1. A physician, and the home health agency is in violation
171 of paragraph (g) (h) or paragraph (h) (i);
172 2. A member of the physician’s office staff; or
173 3. An immediate family member of the physician,
174
175 if the home health agency has received a patient referral in the
176 preceding 12 months from that physician or physician’s office
177 staff.
178 (j)(k) Fails to provide to the agency, upon request, copies
179 of all contracts with a medical director which were executed
180 within 5 years before the request.
181 (k)(l) Demonstrates a pattern of billing the Medicaid
182 program for services to Medicaid recipients which are medically
183 unnecessary as determined by a final order. A pattern may be
184 demonstrated by a showing of at least two such medically
185 unnecessary services within one Medicaid program integrity audit
186 period.
187
188 Paragraphs (e) and (i) do not apply to or preclude Nothing in
189 paragraph (e) or paragraph (j) shall be interpreted as applying
190 to or precluding any discount, compensation, waiver of payment,
191 or payment practice permitted by 42 U.S.C. s. 1320a-7(b) or
192 regulations adopted thereunder, including 42 C.F.R. s. 1001.952
193 or s. 1395nn or regulations adopted thereunder.
194 (7) The agency shall impose a fine of $50 per day against a
195 home health agency that fails to submit to the agency, within 15
196 days after the end of each calendar quarter, a written report
197 that includes the following data based on data as it existed on
198 the last day of the quarter:
199 (a) The number of patients receiving both home health
200 services from the home health agency and hospice services;
201 (b) The number of patients receiving home health services
202 from the home health agency;
203 (c) The number of insulin-dependent diabetic patients
204 receiving insulin-injection services from the home health
205 agency; and
206 (d) The names and license numbers of nurses whose primary
207 job responsibility is to provide home health services to
208 patients and who received remuneration from the home health
209 agency in excess of $25,000 during the calendar quarter.
210 Section 2. Paragraph (i) of subsection (4) of section
211 409.221, Florida Statutes, is amended to read:
212 409.221 Consumer-directed care program.—
213 (4) CONSUMER-DIRECTED CARE.—
214 (i) Background screening requirements.—All persons who
215 render care under this section must undergo level 2 background
216 screening pursuant to chapter 435 and s. 408.809. The agency
217 shall, as allowable, reimburse consumer-employed caregivers for
218 the cost of conducting such background screening as required by
219 this section. For purposes of this section, a person who has
220 undergone screening, who is qualified for employment under this
221 section and applicable rule, and who has not been unemployed for
222 more than 90 days following such screening is not required to be
223 rescreened. Such person must attest under penalty of perjury to
224 not having been convicted of a disqualifying offense since
225 completing such screening.
226 Section 3. Paragraph (c) of subsection (3) of section
227 409.907, Florida Statutes, is amended, paragraph (k) is added to
228 that subsection, and subsections (6), (7), and (8) of that
229 section are amended, to read:
230 409.907 Medicaid provider agreements.—The agency may make
231 payments for medical assistance and related services rendered to
232 Medicaid recipients only to an individual or entity who has a
233 provider agreement in effect with the agency, who is performing
234 services or supplying goods in accordance with federal, state,
235 and local law, and who agrees that no person shall, on the
236 grounds of handicap, race, color, or national origin, or for any
237 other reason, be subjected to discrimination under any program
238 or activity for which the provider receives payment from the
239 agency.
240 (3) The provider agreement developed by the agency, in
241 addition to the requirements specified in subsections (1) and
242 (2), shall require the provider to:
243 (c) Retain all medical and Medicaid-related records for 6 a
244 period of 5 years to satisfy all necessary inquiries by the
245 agency.
246 (k) Report a change in any principal of the provider,
247 including any officer, director, agent, managing employee, or
248 affiliated person, or any partner or shareholder who has an
249 ownership interest equal to 5 percent or more in the provider,
250 to the agency in writing no later than 30 days after the change
251 occurs.
252 (6) A Medicaid provider agreement may be revoked, at the
253 option of the agency, due to as the result of a change of
254 ownership of any facility, association, partnership, or other
255 entity named as the provider in the provider agreement.
256 (a) In the event of a change of ownership, the transferor
257 remains liable for all outstanding overpayments, administrative
258 fines, and any other moneys owed to the agency before the
259 effective date of the change of ownership. In addition to the
260 continuing liability of the transferor, The transferee is also
261 liable to the agency for all outstanding overpayments identified
262 by the agency on or before the effective date of the change of
263 ownership. For purposes of this subsection, the term
264 “outstanding overpayment” includes any amount identified in a
265 preliminary audit report issued to the transferor by the agency
266 on or before the effective date of the change of ownership. In
267 the event of a change of ownership for a skilled nursing
268 facility or intermediate care facility, the Medicaid provider
269 agreement shall be assigned to the transferee if the transferee
270 meets all other Medicaid provider qualifications. In the event
271 of a change of ownership involving a skilled nursing facility
272 licensed under part II of chapter 400, liability for all
273 outstanding overpayments, administrative fines, and any moneys
274 owed to the agency before the effective date of the change of
275 ownership shall be determined in accordance with s. 400.179.
276 (b) At least 60 days before the anticipated date of the
277 change of ownership, the transferor must shall notify the agency
278 of the intended change of ownership and the transferee must
279 shall submit to the agency a Medicaid provider enrollment
280 application. If a change of ownership occurs without compliance
281 with the notice requirements of this subsection, the transferor
282 and transferee are shall be jointly and severally liable for all
283 overpayments, administrative fines, and other moneys due to the
284 agency, regardless of whether the agency identified the
285 overpayments, administrative fines, or other moneys before or
286 after the effective date of the change of ownership. The agency
287 may not approve a transferee’s Medicaid provider enrollment
288 application if the transferee or transferor has not paid or
289 agreed in writing to a payment plan for all outstanding
290 overpayments, administrative fines, and other moneys due to the
291 agency. This subsection does not preclude the agency from
292 seeking any other legal or equitable remedies available to the
293 agency for the recovery of moneys owed to the Medicaid program.
294 In the event of a change of ownership involving a skilled
295 nursing facility licensed under part II of chapter 400,
296 liability for all outstanding overpayments, administrative
297 fines, and any moneys owed to the agency before the effective
298 date of the change of ownership shall be determined in
299 accordance with s. 400.179 if the Medicaid provider enrollment
300 application for change of ownership is submitted before the
301 change of ownership.
302 (c) As used in this subsection, the term:
303 1. “Administrative fines” includes any amount identified in
304 a notice of a monetary penalty or fine which has been issued by
305 the agency or other regulatory or licensing agency that governs
306 the provider.
307 2. “Outstanding overpayment” includes any amount identified
308 in a preliminary audit report issued to the transferor by the
309 agency on or before the effective date of a change of ownership.
310 (7) The agency may require, As a condition of participating
311 in the Medicaid program and before entering into the provider
312 agreement, the agency may require that the provider to submit
313 information, in an initial and any required renewal
314 applications, concerning the professional, business, and
315 personal background of the provider and permit an onsite
316 inspection of the provider’s service location by agency staff or
317 other personnel designated by the agency to perform this
318 function. Before entering into a provider agreement, the agency
319 may shall perform an a random onsite inspection, within 60 days
320 after receipt of a fully complete new provider’s application, of
321 the provider’s service location prior to making its first
322 payment to the provider for Medicaid services to determine the
323 applicant’s ability to provide the services in compliance with
324 the Medicaid program and professional regulations that the
325 applicant is proposing to provide for Medicaid reimbursement.
326 The agency is not required to perform an onsite inspection of a
327 provider or program that is licensed by the agency, that
328 provides services under waiver programs for home and community
329 based services, or that is licensed as a medical foster home by
330 the Department of Children and Family Services. As a continuing
331 condition of participation in the Medicaid program, a provider
332 must shall immediately notify the agency of any current or
333 pending bankruptcy filing. Before entering into the provider
334 agreement, or as a condition of continuing participation in the
335 Medicaid program, the agency may also require that Medicaid
336 providers reimbursed on a fee-for-services basis or fee schedule
337 basis that which is not cost-based, post a surety bond not to
338 exceed $50,000 or the total amount billed by the provider to the
339 program during the current or most recent calendar year,
340 whichever is greater. For new providers, the amount of the
341 surety bond shall be determined by the agency based on the
342 provider’s estimate of its first year’s billing. If the
343 provider’s billing during the first year exceeds the bond
344 amount, the agency may require the provider to acquire an
345 additional bond equal to the actual billing level of the
346 provider. A provider’s bond may shall not exceed $50,000 if a
347 physician or group of physicians licensed under chapter 458,
348 chapter 459, or chapter 460 has a 50 percent or greater
349 ownership interest in the provider or if the provider is an
350 assisted living facility licensed under chapter 429. The bonds
351 permitted by this section are in addition to the bonds
352 referenced in s. 400.179(2)(d). If the provider is a
353 corporation, partnership, association, or other entity, the
354 agency may require the provider to submit information concerning
355 the background of that entity and of any principal of the
356 entity, including any partner or shareholder having an ownership
357 interest in the entity equal to 5 percent or greater, and any
358 treating provider who participates in or intends to participate
359 in Medicaid through the entity. The information must include:
360 (a) Proof of holding a valid license or operating
361 certificate, as applicable, if required by the state or local
362 jurisdiction in which the provider is located or if required by
363 the Federal Government.
364 (b) Information concerning any prior violation, fine,
365 suspension, termination, or other administrative action taken
366 under the Medicaid laws, rules, or regulations of this state or
367 of any other state or the Federal Government; any prior
368 violation of the laws, rules, or regulations relating to the
369 Medicare program; any prior violation of the rules or
370 regulations of any other public or private insurer; and any
371 prior violation of the laws, rules, or regulations of any
372 regulatory body of this or any other state.
373 (c) Full and accurate disclosure of any financial or
374 ownership interest that the provider, or any principal, partner,
375 or major shareholder thereof, may hold in any other Medicaid
376 provider or health care related entity or any other entity that
377 is licensed by the state to provide health or residential care
378 and treatment to persons.
379 (d) If a group provider, identification of all members of
380 the group and attestation that all members of the group are
381 enrolled in or have applied to enroll in the Medicaid program.
382 (8)(a) Each provider, or each principal of the provider if
383 the provider is a corporation, partnership, association, or
384 other entity, seeking to participate in the Medicaid program
385 must submit a complete set of his or her fingerprints to the
386 agency for the purpose of conducting a criminal history record
387 check. Principals of the provider include any officer, director,
388 billing agent, managing employee, or affiliated person, or any
389 partner or shareholder who has an ownership interest equal to 5
390 percent or more in the provider. However, for a hospital
391 licensed under chapter 395 or a nursing home licensed under
392 chapter 400, principals of the provider are those who meet the
393 definition of a controlling interest under s. 408.803. A
394 director of a not-for-profit corporation or organization is not
395 a principal for purposes of a background investigation as
396 required by this section if the director: serves solely in a
397 voluntary capacity for the corporation or organization, does not
398 regularly take part in the day-to-day operational decisions of
399 the corporation or organization, receives no remuneration from
400 the not-for-profit corporation or organization for his or her
401 service on the board of directors, has no financial interest in
402 the not-for-profit corporation or organization, and has no
403 family members with a financial interest in the not-for-profit
404 corporation or organization; and if the director submits an
405 affidavit, under penalty of perjury, to this effect to the
406 agency and the not-for-profit corporation or organization
407 submits an affidavit, under penalty of perjury, to this effect
408 to the agency as part of the corporation’s or organization’s
409 Medicaid provider agreement application.
410 (a) Notwithstanding the above, the agency may require a
411 background check for any person reasonably suspected by the
412 agency to have been convicted of a crime. This subsection does
413 not apply to:
414 1. A hospital licensed under chapter 395;
415 2. A nursing home licensed under chapter 400;
416 3. A hospice licensed under chapter 400;
417 4. An assisted living facility licensed under chapter 429;
418 1.5. A unit of local government, except that requirements
419 of this subsection apply to nongovernmental providers and
420 entities contracting with the local government to provide
421 Medicaid services. The actual cost of the state and national
422 criminal history record checks must be borne by the
423 nongovernmental provider or entity; or
424 2.6. Any business that derives more than 50 percent of its
425 revenue from the sale of goods to the final consumer, and the
426 business or its controlling parent is required to file a form
427 10-K or other similar statement with the Securities and Exchange
428 Commission or has a net worth of $50 million or more.
429 (b) Background screening shall be conducted in accordance
430 with chapter 435 and s. 408.809. The cost of the state and
431 national criminal record check shall be borne by the provider.
432 (c) Proof of compliance with the requirements of level 2
433 screening under chapter 435 conducted within 12 months before
434 the date the Medicaid provider application is submitted to the
435 agency fulfills the requirements of this subsection.
436 Section 4. Present paragraphs (e) and (f) of subsection (1)
437 of section 409.913, Florida Statutes, are redesignated as
438 paragraphs (f) and (g), respectively, a new paragraph (e) is
439 added to that subsection, and subsections (2), (9), (13), (15),
440 (16), (21), (22), (25), (28), (29), (30), and (31) of that
441 section are amended, to read:
442 409.913 Oversight of the integrity of the Medicaid
443 program.—The agency shall operate a program to oversee the
444 activities of Florida Medicaid recipients, and providers and
445 their representatives, to ensure that fraudulent and abusive
446 behavior and neglect of recipients occur to the minimum extent
447 possible, and to recover overpayments and impose sanctions as
448 appropriate. Beginning January 1, 2003, and each year
449 thereafter, the agency and the Medicaid Fraud Control Unit of
450 the Department of Legal Affairs shall submit a joint report to
451 the Legislature documenting the effectiveness of the state’s
452 efforts to control Medicaid fraud and abuse and to recover
453 Medicaid overpayments during the previous fiscal year. The
454 report must describe the number of cases opened and investigated
455 each year; the sources of the cases opened; the disposition of
456 the cases closed each year; the amount of overpayments alleged
457 in preliminary and final audit letters; the number and amount of
458 fines or penalties imposed; any reductions in overpayment
459 amounts negotiated in settlement agreements or by other means;
460 the amount of final agency determinations of overpayments; the
461 amount deducted from federal claiming as a result of
462 overpayments; the amount of overpayments recovered each year;
463 the amount of cost of investigation recovered each year; the
464 average length of time to collect from the time the case was
465 opened until the overpayment is paid in full; the amount
466 determined as uncollectible and the portion of the uncollectible
467 amount subsequently reclaimed from the Federal Government; the
468 number of providers, by type, that are terminated from
469 participation in the Medicaid program as a result of fraud and
470 abuse; and all costs associated with discovering and prosecuting
471 cases of Medicaid overpayments and making recoveries in such
472 cases. The report must also document actions taken to prevent
473 overpayments and the number of providers prevented from
474 enrolling in or reenrolling in the Medicaid program as a result
475 of documented Medicaid fraud and abuse and must include policy
476 recommendations necessary to prevent or recover overpayments and
477 changes necessary to prevent and detect Medicaid fraud. All
478 policy recommendations in the report must include a detailed
479 fiscal analysis, including, but not limited to, implementation
480 costs, estimated savings to the Medicaid program, and the return
481 on investment. The agency must submit the policy recommendations
482 and fiscal analyses in the report to the appropriate estimating
483 conference, pursuant to s. 216.137, by February 15 of each year.
484 The agency and the Medicaid Fraud Control Unit of the Department
485 of Legal Affairs each must include detailed unit-specific
486 performance standards, benchmarks, and metrics in the report,
487 including projected cost savings to the state Medicaid program
488 during the following fiscal year.
489 (1) For the purposes of this section, the term:
490 (e) “Medicaid provider” or “provider” has the same meaning
491 as provided in s. 409.901 and, for purposes of oversight of the
492 integrity of the Medicaid program, also includes a participant
493 in a Medicaid managed care provider network.
494 (2) The agency shall conduct, or cause to be conducted by
495 contract or otherwise, reviews, investigations, analyses,
496 audits, or any combination thereof, to determine possible fraud,
497 abuse, overpayment, or recipient neglect in the Medicaid program
498 and shall report the findings of any overpayments in audit
499 reports as appropriate. At least 5 percent of all audits must
500 shall be conducted on a random basis. As part of its ongoing
501 fraud detection activities, the agency shall identify and
502 monitor, by contract or otherwise, patterns of overutilization
503 of Medicaid services based on state averages. The agency shall
504 track Medicaid provider prescription and billing patterns and
505 evaluate them against Medicaid medical necessity criteria and
506 coverage and limitation guidelines adopted by rule. Medical
507 necessity determination requires that service be consistent with
508 symptoms or confirmed diagnosis of illness or injury under
509 treatment and not in excess of the patient’s needs. The agency
510 shall conduct reviews of provider exceptions to peer group norms
511 and shall, using statistical methodologies, provider profiling,
512 and analysis of billing patterns, detect and investigate
513 abnormal or unusual increases in billing or payment of claims
514 for Medicaid services and medically unnecessary provision of
515 services. The agency may review and analyze information from
516 sources other than enrolled Medicaid providers in conducting its
517 activities under this subsection.
518 (9) A Medicaid provider shall retain medical, professional,
519 financial, and business records pertaining to services and goods
520 furnished to a Medicaid recipient and billed to Medicaid for 6 a
521 period of 5 years after the date of furnishing such services or
522 goods. The agency may investigate, review, or analyze such
523 records, which must be made available during normal business
524 hours. However, 24-hour notice must be provided if patient
525 treatment would be disrupted. The provider is responsible for
526 furnishing to the agency, and keeping the agency informed of the
527 location of, the provider’s Medicaid-related records. The
528 authority of the agency to obtain Medicaid-related records from
529 a provider is neither curtailed nor limited during a period of
530 litigation between the agency and the provider.
531 (13) The agency shall immediately terminate participation
532 of a Medicaid provider in the Medicaid program and may seek
533 civil remedies or impose other administrative sanctions against
534 a Medicaid provider, if the provider or any principal, officer,
535 director, agent, managing employee, or affiliated person of the
536 provider, or any partner or shareholder having an ownership
537 interest in the provider equal to 5 percent or greater, has been
538 convicted of a criminal offense under federal law or the law of
539 any state relating to the practice of the provider’s profession,
540 or an offense listed under s. 409.907(10), s. 408.809(4), or s.
541 435.04(2) has been:
542 (a) Convicted of a criminal offense related to the delivery
543 of any health care goods or services, including the performance
544 of management or administrative functions relating to the
545 delivery of health care goods or services;
546 (b) Convicted of a criminal offense under federal law or
547 the law of any state relating to the practice of the provider’s
548 profession; or
549 (c) Found by a court of competent jurisdiction to have
550 neglected or physically abused a patient in connection with the
551 delivery of health care goods or services. If the agency
552 determines that the a provider did not participate or acquiesce
553 in the an offense specified in paragraph (a), paragraph (b), or
554 paragraph (c), termination will not be imposed. If the agency
555 effects a termination under this subsection, the agency shall
556 issue an immediate final order pursuant to s. 120.569(2)(n).
557 (15) The agency shall seek a remedy provided by law,
558 including, but not limited to, any remedy provided in
559 subsections (13) and (16) and s. 812.035, if:
560 (a) The provider’s license has not been renewed, or has
561 been revoked, suspended, or terminated, for cause, by the
562 licensing agency of any state;
563 (b) The provider has failed to make available or has
564 refused access to Medicaid-related records to an auditor,
565 investigator, or other authorized employee or agent of the
566 agency, the Attorney General, a state attorney, or the Federal
567 Government;
568 (c) The provider has not furnished or has failed to make
569 available such Medicaid-related records as the agency has found
570 necessary to determine whether Medicaid payments are or were due
571 and the amounts thereof;
572 (d) The provider has failed to maintain medical records
573 made at the time of service, or prior to service if prior
574 authorization is required, demonstrating the necessity and
575 appropriateness of the goods or services rendered;
576 (e) The provider is not in compliance with provisions of
577 Medicaid provider publications that have been adopted by
578 reference as rules in the Florida Administrative Code; with
579 provisions of state or federal laws, rules, or regulations; with
580 provisions of the provider agreement between the agency and the
581 provider; or with certifications found on claim forms or on
582 transmittal forms for electronically submitted claims that are
583 submitted by the provider or authorized representative, as such
584 provisions apply to the Medicaid program;
585 (f) The provider or person who ordered or prescribed the
586 care, services, or supplies has furnished, or ordered, or
587 authorized the furnishing of, goods or services to a recipient
588 which are inappropriate, unnecessary, excessive, or harmful to
589 the recipient or are of inferior quality;
590 (g) The provider has demonstrated a pattern of failure to
591 provide goods or services that are medically necessary;
592 (h) The provider or an authorized representative of the
593 provider, or a person who ordered or prescribed the goods or
594 services, has submitted or caused to be submitted false or a
595 pattern of erroneous Medicaid claims;
596 (i) The provider or an authorized representative of the
597 provider, or a person who has ordered, authorized, or prescribed
598 the goods or services, has submitted or caused to be submitted a
599 Medicaid provider enrollment application, a request for prior
600 authorization for Medicaid services, a drug exception request,
601 or a Medicaid cost report that contains materially false or
602 incorrect information;
603 (j) The provider or an authorized representative of the
604 provider has collected from or billed a recipient or a
605 recipient’s responsible party improperly for amounts that should
606 not have been so collected or billed by reason of the provider’s
607 billing the Medicaid program for the same service;
608 (k) The provider or an authorized representative of the
609 provider has included in a cost report costs that are not
610 allowable under a Florida Title XIX reimbursement plan, after
611 the provider or authorized representative had been advised in an
612 audit exit conference or audit report that the costs were not
613 allowable;
614 (l) The provider is charged by information or indictment
615 with fraudulent billing practices or any offense referenced in
616 subsection (13). The sanction applied for this reason is limited
617 to suspension of the provider’s participation in the Medicaid
618 program for the duration of the indictment unless the provider
619 is found guilty pursuant to the information or indictment;
620 (m) The provider or a person who has ordered or prescribed
621 the goods or services is found liable for negligent practice
622 resulting in death or injury to the provider’s patient;
623 (n) The provider fails to demonstrate that it had available
624 during a specific audit or review period sufficient quantities
625 of goods, or sufficient time in the case of services, to support
626 the provider’s billings to the Medicaid program;
627 (o) The provider has failed to comply with the notice and
628 reporting requirements of s. 409.907;
629 (p) The agency has received reliable information of patient
630 abuse or neglect or of any act prohibited by s. 409.920; or
631 (q) The provider has failed to comply with an agreed-upon
632 repayment schedule.
633
634 A provider is subject to sanctions for violations of this
635 subsection as the result of actions or inactions of the
636 provider, or actions or inactions of any principal, officer,
637 director, agent, managing employee, or affiliated person of the
638 provider, or any partner or shareholder having an ownership
639 interest in the provider equal to 5 percent or greater, in which
640 the provider participated or acquiesced.
641 (16) The agency shall impose any of the following sanctions
642 or disincentives on a provider or a person for any of the acts
643 described in subsection (15):
644 (a) Suspension for a specific period of time of not more
645 than 1 year. Suspension precludes shall preclude participation
646 in the Medicaid program, which includes any action that results
647 in a claim for payment to the Medicaid program as a result of
648 furnishing, supervising a person who is furnishing, or causing a
649 person to furnish goods or services.
650 (b) Termination for a specific period of time of from more
651 than 1 year to 20 years. Termination precludes shall preclude
652 participation in the Medicaid program, which includes any action
653 that results in a claim for payment to the Medicaid program as a
654 result of furnishing, supervising a person who is furnishing, or
655 causing a person to furnish goods or services.
656 (c) Imposition of a fine of up to $5,000 for each
657 violation. Each day that an ongoing violation continues, such as
658 refusing to furnish Medicaid-related records or refusing access
659 to records, is considered, for the purposes of this section, to
660 be a separate violation. Each instance of improper billing of a
661 Medicaid recipient; each instance of including an unallowable
662 cost on a hospital or nursing home Medicaid cost report after
663 the provider or authorized representative has been advised in an
664 audit exit conference or previous audit report of the cost
665 unallowability; each instance of furnishing a Medicaid recipient
666 goods or professional services that are inappropriate or of
667 inferior quality as determined by competent peer judgment; each
668 instance of knowingly submitting a materially false or erroneous
669 Medicaid provider enrollment application, request for prior
670 authorization for Medicaid services, drug exception request, or
671 cost report; each instance of inappropriate prescribing of drugs
672 for a Medicaid recipient as determined by competent peer
673 judgment; and each false or erroneous Medicaid claim leading to
674 an overpayment to a provider is considered, for the purposes of
675 this section, to be a separate violation.
676 (d) Immediate suspension, if the agency has received
677 information of patient abuse or neglect or of any act prohibited
678 by s. 409.920. Upon suspension, the agency must issue an
679 immediate final order under s. 120.569(2)(n).
680 (e) A fine, not to exceed $10,000, for a violation of
681 paragraph (15)(i).
682 (f) Imposition of liens against provider assets, including,
683 but not limited to, financial assets and real property, not to
684 exceed the amount of fines or recoveries sought, upon entry of
685 an order determining that such moneys are due or recoverable.
686 (g) Prepayment reviews of claims for a specified period of
687 time.
688 (h) Comprehensive followup reviews of providers every 6
689 months to ensure that they are billing Medicaid correctly.
690 (i) Corrective-action plans that would remain in effect for
691 providers for up to 3 years and that are would be monitored by
692 the agency every 6 months while in effect.
693 (j) Other remedies as permitted by law to effect the
694 recovery of a fine or overpayment.
695
696 If a provider voluntarily relinquishes its Medicaid provider
697 number after receiving written notice that the agency is
698 conducting, or has conducted, an audit or investigation and the
699 sanction of suspension or termination will be imposed for
700 noncompliance discovered as a result of the audit or
701 investigation, the agency shall impose the sanction of
702 termination for cause against the provider. The Secretary of
703 Health Care Administration may make a determination that
704 imposition of a sanction or disincentive is not in the best
705 interest of the Medicaid program, in which case a sanction or
706 disincentive may shall not be imposed.
707 (21) When making a determination that an overpayment has
708 occurred, the agency shall prepare and issue an audit report to
709 the provider showing the calculation of overpayments. The
710 agency’s determination shall be based solely upon information
711 available to it before issuance of the audit report and, in the
712 case of documentation obtained to substantiate claims for
713 Medicaid reimbursement, based solely upon contemporaneous
714 records.
715 (22) The audit report, supported by agency work papers,
716 showing an overpayment to a provider constitutes evidence of the
717 overpayment. A provider may not present or elicit testimony,
718 either on direct examination or cross-examination in any court
719 or administrative proceeding, regarding the purchase or
720 acquisition by any means of drugs, goods, or supplies; sales or
721 divestment by any means of drugs, goods, or supplies; or
722 inventory of drugs, goods, or supplies, unless such acquisition,
723 sales, divestment, or inventory is documented by written
724 invoices, written inventory records, or other competent written
725 documentary evidence maintained in the normal course of the
726 provider’s business. Testimony or evidence that is not based
727 upon contemporaneous records or that was not furnished to the
728 agency within 21 days after the issuance of the audit report is
729 inadmissible in an administrative hearing on a Medicaid
730 overpayment or an administrative sanction. Notwithstanding the
731 applicable rules of discovery, all documentation to that will be
732 offered as evidence at an administrative hearing on a Medicaid
733 overpayment or an administrative sanction must be exchanged by
734 all parties at least 14 days before the administrative hearing
735 or must be excluded from consideration.
736 (25)(a) The agency shall withhold Medicaid payments, in
737 whole or in part, to a provider upon receipt of reliable
738 evidence that the circumstances giving rise to the need for a
739 withholding of payments involve fraud, willful
740 misrepresentation, or abuse under the Medicaid program, or a
741 crime committed while rendering goods or services to Medicaid
742 recipients. If it is determined that fraud, willful
743 misrepresentation, abuse, or a crime did not occur, the payments
744 withheld must be paid to the provider within 14 days after such
745 determination with interest at the rate of 10 percent a year.
746 Any money withheld in accordance with this paragraph shall be
747 placed in a suspended account, readily accessible to the agency,
748 so that any payment ultimately due the provider shall be made
749 within 14 days.
750 (b) The agency shall deny payment, or require repayment, if
751 the goods or services were furnished, supervised, or caused to
752 be furnished by a person who has been suspended or terminated
753 from the Medicaid program or Medicare program by the Federal
754 Government or any state.
755 (c) Overpayments owed to the agency bear interest at the
756 rate of 10 percent per year from the date of determination of
757 the overpayment by the agency, and payment arrangements
758 regarding overpayments and fines must be made within 30 days
759 after the date of the final order and are not subject to further
760 appeal at the conclusion of legal proceedings. A provider who
761 does not enter into or adhere to an agreed-upon repayment
762 schedule may be terminated by the agency for nonpayment or
763 partial payment.
764 (d) The agency, upon entry of a final agency order, a
765 judgment or order of a court of competent jurisdiction, or a
766 stipulation or settlement, may collect the moneys owed by all
767 means allowable by law, including, but not limited to, notifying
768 any fiscal intermediary of Medicare benefits that the state has
769 a superior right of payment. Upon receipt of such written
770 notification, the Medicare fiscal intermediary shall remit to
771 the state the sum claimed.
772 (e) The agency may institute amnesty programs to allow
773 Medicaid providers the opportunity to voluntarily repay
774 overpayments. The agency may adopt rules to administer such
775 programs.
776 (28) Venue for all Medicaid program integrity overpayment
777 cases lies shall lie in Leon County, at the discretion of the
778 agency.
779 (29) Notwithstanding other provisions of law, the agency
780 and the Medicaid Fraud Control Unit of the Department of Legal
781 Affairs may review a person’s or provider’s Medicaid-related and
782 non-Medicaid-related records in order to determine the total
783 output of a provider’s practice to reconcile quantities of goods
784 or services billed to Medicaid with quantities of goods or
785 services used in the provider’s total practice.
786 (30) The agency shall terminate a provider’s participation
787 in the Medicaid program if the provider fails to reimburse an
788 overpayment or fine that has been determined by final order, not
789 subject to further appeal, within 30 35 days after the date of
790 the final order, unless the provider and the agency have entered
791 into a repayment agreement.
792 (31) If a provider requests an administrative hearing
793 pursuant to chapter 120, such hearing must be conducted within
794 90 days following assignment of an administrative law judge,
795 absent exceptionally good cause shown as determined by the
796 administrative law judge or hearing officer. Upon issuance of a
797 final order, the outstanding balance of the amount determined to
798 constitute the overpayment and fines is shall become due. If a
799 provider fails to make payments in full, fails to enter into a
800 satisfactory repayment plan, or fails to comply with the terms
801 of a repayment plan or settlement agreement, the agency shall
802 withhold medical assistance reimbursement payments for Medicaid
803 services until the amount due is paid in full.
804 Section 5. Subsection (8) of section 409.920, Florida
805 Statutes, is amended to read:
806 409.920 Medicaid provider fraud.—
807 (8) A person who provides the state, any state agency, any
808 of the state’s political subdivisions, or any agency of the
809 state’s political subdivisions with information about fraud or
810 suspected fraudulent acts fraud by a Medicaid provider,
811 including a managed care organization, is immune from civil
812 liability for libel, slander, or any other relevant tort for
813 providing any the information about fraud or suspected
814 fraudulent acts, unless the person acted with knowledge that the
815 information was false or with reckless disregard for the truth
816 or falsity of the information. For purposes of this subsection,
817 the term “fraudulent acts” includes actual or suspected fraud,
818 abuse, or overpayment, including any fraud-related matters that
819 a provider or health plan is required to report to the agency or
820 a law enforcement agency. The immunity from civil liability
821 extends to reports of fraudulent acts conveyed to the agency in
822 any manner, including any forum and with any audience as
823 directed by the agency, and includes all discussions subsequent
824 to the report and subsequent inquiries from the agency, unless
825 the person acted with knowledge that the information was false
826 or with reckless disregard for the truth or falsity of the
827 information.
828 Section 6. Paragraph (c) of subsection (2) of section
829 409.967, Florida Statutes, is amended to read:
830 409.967 Managed care plan accountability.—
831 (2) The agency shall establish such contract requirements
832 as are necessary for the operation of the statewide managed care
833 program. In addition to any other provisions the agency may deem
834 necessary, the contract must require:
835 (c) Access.—
836 1. Providers.—The agency shall establish specific standards
837 for the number, type, and regional distribution of providers in
838 managed care plan networks to ensure access to care for both
839 adults and children. Each plan must maintain a regionwide
840 network of providers in sufficient numbers to meet the access
841 standards for specific medical services for all recipients
842 enrolled in the plan. The exclusive use of mail-order pharmacies
843 is may not be sufficient to meet network access standards.
844 Consistent with the standards established by the agency,
845 provider networks may include providers located outside the
846 region. A plan may contract with a new hospital facility before
847 the date the hospital becomes operational if the hospital has
848 commenced construction, will be licensed and operational by
849 January 1, 2013, and a final order has issued in any civil or
850 administrative challenge. Each plan shall establish and maintain
851 an accurate and complete electronic database of contracted
852 providers, including information about licensure or
853 registration, locations and hours of operation, specialty
854 credentials and other certifications, specific performance
855 indicators, and such other information as the agency deems
856 necessary. The database must be available online to both the
857 agency and the public and have the capability to compare the
858 availability of providers to network adequacy standards and to
859 accept and display feedback from each provider’s patients. Each
860 plan shall submit quarterly reports to the agency identifying
861 the number of enrollees assigned to each primary care provider.
862 2. Prescribed drugs.—
863 a. If establishing a prescribed drug formulary or preferred
864 drug list, a managed care plan must:
865 (I) Provide coverage for drugs in categories and classes
866 for all disease states and provide a broad range of therapeutic
867 options for all therapeutic categories;
868 (II) Include coverage for each drug newly approved by the
869 federal Food and Drug Administration until the plan’s
870 Pharmaceutical and Therapeutics Committee reviews such drug for
871 inclusion on the formulary;
872 (III) Provide a response within 24 hours after receipt of
873 all necessary information for a request for prior authorization
874 or override of other medical management tools; and
875 (IV) Report all denials to the agency on a quarterly basis.
876 For each nonformulary drug, the plan must report the total
877 number of requests and the total number of denials.
878 b. Each managed care plan shall must publish any prescribed
879 drug formulary or preferred drug list on the plan’s website in a
880 manner that is accessible to and searchable by enrollees and
881 providers. The plan must update the list within 24 hours after
882 making a change. Each plan must ensure that the prior
883 authorization process for prescribed drugs is readily accessible
884 to health care providers, including posting appropriate contact
885 information on its website and providing timely responses to
886 providers.
887 c. The managed care plan must continue to permit an
888 enrollee who was receiving a prescription drug that was on the
889 plan’s formulary and subsequently removed or changed to continue
890 to receive that drug if requested by the enrollee and prescriber
891 for as long as the enrollee is a member of the plan.
892 d. A managed care plan that imposes a step-therapy or a
893 fail-first protocol must do so in accordance with the following:
894 (I) If prescribed drugs for the treatment of a medical
895 condition are restricted for use by the plan through a step
896 therapy or fail-first protocol, the plan must provide the
897 prescriber with access to a clear and convenient process to
898 expeditiously request an override of such restriction from the
899 insurer.
900 (II) An override of the restriction must be expeditiously
901 granted by the plan if the prescriber can demonstrate to the
902 plan that the preferred treatment required under the step
903 therapy or fail-first protocol:
904 (A) Has been ineffective in the treatment of the enrollee’s
905 disease or medical condition;
906 (B) Is reasonably expected to be ineffective based on the
907 known relevant physical or mental characteristics and medical
908 history of the enrollee and known characteristics of the drug
909 regimen; or
910 (C) Will cause or will likely cause an adverse reaction or
911 other physical harm to the enrollee.
912 (III) The maximum duration of a step-therapy or fail-first
913 protocol requirement may not be longer than the customary period
914 for the prescribed drug if such treatment is demonstrated by the
915 prescriber to be clinically ineffective. If the plan can
916 demonstrate, through sound clinical evidence, that the
917 originally prescribed drug is likely to require more than the
918 customary period for such drug to provide any relief or
919 amelioration to the enrollee, the step-therapy or fail-first
920 protocol may be extended, but no longer than the original
921 customary period for the drug, after which time the prescriber
922 may deem such treatment as clinically ineffective for the
923 enrollee. Once the prescriber deems the treatment to be
924 clinically ineffective, the plan must dispense and cover the
925 originally prescribed drug recommended by the prescriber.
926 e. For enrollees Medicaid recipients diagnosed with
927 hemophilia who have been prescribed anti-hemophilic-factor
928 replacement products, the agency shall provide for those
929 products and hemophilia overlay services through the agency’s
930 hemophilia disease management program.
931 3. Prior authorization.—
932 a. Each managed care plan must ensure that the prior
933 authorization process for prescribed drugs is readily accessible
934 to health care providers, including posting appropriate contact
935 information on its website and providing timely responses to
936 providers.
937 b. If a drug, determined to be medically necessary and
938 prescribed for an enrollee by a physician using sound clinical
939 judgment, is subject to prior authorization, the managed care
940 plan must provide payment to the pharmacist for dispensing such
941 drug without seeking prior authorization if the pharmacist
942 confirms that:
943 (I) The prescription is a refill or renewal of the same
944 drug for the same beneficiary written by the same prescriber; or
945 (II) If the drug is generally prescribed for an indication
946 that is treated on an ongoing basis by continuous medication or
947 as-needed, the enrollee for whom the drug is prescribed has
948 filled a prescription for the same drug within the preceding 30
949 to 90 days.
950 c. If a prescribed drug requires prior authorization, the
951 managed care plan shall reimburse the pharmacist for dispensing
952 a 72-hour supply to the enrollee and process the prior
953 authorization request and send a response to the requesting
954 pharmacist within 24 hours after receiving the pharmacist’s
955 request for prior authorization.
956 d.3. Managed care plans, and their fiscal agents or
957 intermediaries, must accept prior authorization requests for any
958 service electronically.
959 Section 7. Subsection (11) is added to section 429.23,
960 Florida Statutes, to read:
961 429.23 Internal risk management and quality assurance
962 program; adverse incidents and reporting requirements.—
963 (11) The agency shall annually submit a report to the
964 Legislature on adverse incident reports by assisted living
965 facilities. The report must include the following information
966 arranged by county:
967 (a) A total number of adverse incidents;
968 (b) A listing, by category, of the type of adverse
969 incidents occurring within each category and the type of staff
970 involved;
971 (c) A listing, by category, of the types of injuries, if
972 any, and the number of injuries occurring within each category;
973 (d) Types of liability claims filed based on an adverse
974 incident report or reportable injury; and
975 (e) Disciplinary action taken against staff, categorized by
976 the type of staff involved.
977 Section 8. Present subsections (9), (10), and (11) of
978 section 429.26, Florida Statutes, are renumbered as subsections
979 (12), (13), and (14), respectively, and new subsections (9),
980 (10), and (11) are added to that section, to read:
981 429.26 Appropriateness of placements; examinations of
982 residents.—
983 (9) If, at any time after admission to a facility, agency
984 personnel question whether a resident needs care beyond that
985 which the facility is licensed to provide, the agency may
986 require the resident to be physically examined by a licensed
987 physician, licensed physician assistant, or certified nurse
988 practitioner. To the extent possible, the examination must be
989 performed by the resident’s preferred physician, physician
990 assistant, or nurse practitioner and paid for by the resident
991 with personal funds, except as provided in s. 429.18(2). This
992 subsection does not preclude the agency from imposing sanctions
993 for violations of subsection (1).
994 (a) Following examination, the examining physician,
995 physician assistant, or nurse practitioner shall complete and
996 sign a medical form provided by the agency. The completed
997 medical form must be submitted to the agency within 30 days
998 after the date the facility owner or administrator was notified
999 by the agency that a physical examination is required.
1000 (b) A medical review team designated by the agency shall
1001 determine whether the resident is appropriately residing in the
1002 facility based on the completed medical form and, if necessary,
1003 consultation with the physician, physician assistant, or nurse
1004 practitioner who performed the examination. Members of the
1005 medical review team making the determination may not include the
1006 agency personnel who initially questioned the appropriateness of
1007 the resident’s placement. The medical review team shall base its
1008 decision on a comprehensive review of the resident’s physical
1009 and functional status. A determination that the resident’s
1010 placement is not appropriate is final and binding upon the
1011 facility and the resident.
1012 (c) A resident who is determined by the medical review team
1013 to be inappropriately residing in a facility shall be given 30
1014 days’ written notice to relocate by the owner or administrator,
1015 unless the resident’s continued residence in the facility
1016 presents an imminent danger to the health, safety, or welfare of
1017 the resident or a substantial probability exists that death or
1018 serious physical harm to the resident would result if the
1019 resident is allowed to remain in the facility.
1020 (10) If a mental health resident appears to have needs in
1021 addition to those identified in the community living support
1022 plan, the agency may require an evaluation by a mental health
1023 professional, as determined by the Department of Children and
1024 Family Services.
1025 (11) A facility may not be required to retain a resident
1026 who requires more services or care than the facility is able to
1027 provide in accordance with its policies and criteria for
1028 admission and continued residency.
1029 Section 9. Effective July 1, 2012, section 456.0635,
1030 Florida Statutes, is amended to read:
1031 456.0635 Health care Medicaid fraud; disqualification for
1032 license, certificate, or registration.—
1033 (1) Health care Medicaid fraud in the practice of a health
1034 care profession is prohibited.
1035 (2) Each board under within the jurisdiction of the
1036 department, or the department if there is no board, shall refuse
1037 to admit a candidate to an any examination and refuse to issue
1038 or renew a license, certificate, or registration to an any
1039 applicant if the candidate or applicant or any principal,
1040 officer, agent, managing employee, or affiliated person of the
1041 applicant, has been:
1042 (a) Has been convicted of, or entered a plea of guilty or
1043 nolo contendere to, regardless of adjudication, a felony under
1044 chapter 409, chapter 817, or chapter 893, or a similar felony
1045 offense committed in another state or jurisdiction, unless the
1046 candidate or applicant has successfully completed a pretrial
1047 intervention or drug diversion program for that felony. Any such
1048 conviction or plea excludes the applicant or candidate from
1049 licensure, examination, certification, or registration 21 U.S.C.
1050 ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and
1051 any subsequent period of probation for such conviction or plea
1052 pleas ended: more than 15 years prior to the date of the
1053 application;
1054 1. For felonies of the first or second degree, more than 15
1055 years before the date of application.
1056 2. For felonies of the third degree, more than 10 years
1057 before the date of application, except for felonies of the third
1058 degree under s. 893.13(6)(a).
1059 3. For felonies of the third degree under s. 893.13(6)(a),
1060 more than 5 years before the date of application.
1061 (b) Has been convicted of, or entered a plea of guilty or
1062 nolo contendere to, regardless of adjudication, a felony under
1063 21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396, unless the
1064 sentence and any subsequent period of probation for such
1065 conviction or plea ended more than 15 years before the date of
1066 the application.
1067 (c)(b) Has been terminated for cause from the Florida
1068 Medicaid program pursuant to s. 409.913, unless the candidate or
1069 applicant has been in good standing with the Florida Medicaid
1070 program for the most recent 5 years.;
1071 (d)(c) Has been terminated for cause, pursuant to the
1072 appeals procedures established by the state or Federal
1073 Government, from any other state Medicaid program or the federal
1074 Medicare program, unless the candidate or applicant has been in
1075 good standing with that a state Medicaid program or the federal
1076 Medicare program for the most recent 5 years and the termination
1077 occurred at least 20 years before prior to the date of the
1078 application.
1079 (e) Is currently listed on the United States Department of
1080 Health and Human Services Office of Inspector General’s List of
1081 Excluded Individuals and Entities.
1082
1083 This subsection does not apply to candidates or applicants for
1084 initial licensure or certification who were enrolled in an
1085 educational or training program on or before July 1, 2009, which
1086 was recognized by a board or, if there is no board, recognized
1087 by the department, and who applied for licensure after July 1,
1088 2012.
1089 (3) The department shall refuse to renew a license,
1090 certificate, or registration of any applicant if the applicant
1091 or any principal, officer, agent, managing employee, or
1092 affiliated person of the applicant:
1093 (a) Has been convicted of, or entered a plea of guilty or
1094 nolo contendere to, regardless of adjudication, a felony under
1095 chapter 409, chapter 817, or chapter 893, or a similar felony
1096 offense committed in another state or jurisdiction since July 1,
1097 2009, unless the applicant is currently enrolled in or has
1098 successfully completed a pretrial intervention or drug diversion
1099 program for that felony. Any such conviction or plea excludes
1100 the applicant from renewal of licensure, certification, or
1101 registration unless the sentence and any subsequent period of
1102 probation for such conviction or plea ended:
1103 1. For felonies of the first or second degree, more than 15
1104 years before the date of application.
1105 2. For felonies of the third degree, more than 10 years
1106 before the date of application, except for felonies of the third
1107 degree under s. 893.13(6)(a).
1108 3. For felonies of the third degree under s. 893.13(6)(a),
1109 more than 5 years before the date of application.
1110 (b) Has been convicted of, or entered a plea of guilty or
1111 nolo contendere to, regardless of adjudication, a felony under
1112 21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396 since July 1,
1113 2009, unless the sentence and any subsequent period of probation
1114 for such conviction or plea ended more than 15 years before the
1115 date of the application.
1116 (c) Has been terminated for cause from the Florida Medicaid
1117 program pursuant to s. 409.913, unless the applicant has been in
1118 good standing with the Florida Medicaid program for the most
1119 recent 5 years.
1120 (d) Has been terminated for cause, pursuant to the appeals
1121 procedures established by the state, from any other state
1122 Medicaid program, unless the applicant has been in good standing
1123 with that state Medicaid program for the most recent 5 years and
1124 the termination occurred at least 20 years before the date of
1125 the application.
1126 (e) Is currently listed on the United States Department of
1127 Health and Human Services Office of Inspector General’s List of
1128 Excluded Individuals and Entities.
1129 (4)(3) Licensed health care practitioners shall report
1130 allegations of health care Medicaid fraud to the department,
1131 regardless of the practice setting in which the alleged health
1132 care Medicaid fraud occurred.
1133 (5)(4) The acceptance by a licensing authority of a
1134 licensee’s candidate’s relinquishment of a license which is
1135 offered in response to or anticipation of the filing of
1136 administrative charges alleging health care Medicaid fraud or
1137 similar charges constitutes the permanent revocation of the
1138 license.
1139 Section 10. Effective July 1, 2012, present subsections
1140 (14) and (15) of section 456.036, Florida Statutes, are
1141 renumbered as subsections (15) and (16), respectively, and a new
1142 subsection (14) is added to that section, to read:
1143 456.036 Licenses; active and inactive status; delinquency.—
1144 (14) A person who has been denied license renewal,
1145 certification, or registration under s. 456.0635(3) may regain
1146 licensure, certification, or registration only by meeting the
1147 qualifications and completing the application process for
1148 initial licensure as defined by the board, or the department if
1149 there is no board. However, a person who was denied renewal of
1150 licensure, certification, or registration under s. 24 of chapter
1151 2009-223, Laws of Florida, between July 1, 2009, and June 30,
1152 2012, is not required to retake and pass examinations applicable
1153 for initial licensure, certification, or registration.
1154 Section 11. Subsection (1) of section 456.074, Florida
1155 Statutes, is amended to read:
1156 456.074 Certain health care practitioners; immediate
1157 suspension of license.—
1158 (1) The department shall issue an emergency order
1159 suspending the license of any person licensed under chapter 458,
1160 chapter 459, chapter 460, chapter 461, chapter 462, chapter 463,
1161 chapter 464, chapter 465, chapter 466, or chapter 484 who pleads
1162 guilty to, is convicted or found guilty of, or who enters a plea
1163 of nolo contendere to, regardless of adjudication, to:
1164 (a) A felony under chapter 409, chapter 817, or chapter 893
1165 or under 21 U.S.C. ss. 801-970 or under 42 U.S.C. ss. 1395-1396;
1166 or
1167 (b) A misdemeanor or felony under 18 U.S.C. s. 669, ss.
1168 285-287, s. 371, s. 1001, s. 1035, s. 1341, s. 1343, s. 1347, s.
1169 1349, or s. 1518 or 42 U.S.C. ss. 1320a-7b, relating to the
1170 Medicaid program.
1171 Section 12. The Agency for Health Care Administration shall
1172 prepare a report within 18 months after the implementation of an
1173 expansion of managed care to new populations or the provision of
1174 new items and services. The agency shall post a draft of the
1175 report on its website and provide an opportunity for public
1176 comment. The final report shall be submitted to the Legislature,
1177 along with a description of the process for public input. The
1178 report must include an assessment of:
1179 (1) The impact of managed care on patient access to care,
1180 including an evaluation of any new barriers to the use of
1181 services and prescription drugs, created by the use of medical
1182 management or cost-containment tools.
1183 (2) The impact of the increased managed care expansion on
1184 the utilization of services, quality of care, and patient
1185 outcomes.
1186 (3) The use of prior authorization and other utilization
1187 management tools, including an assessment of whether these tools
1188 pose an undue administrative burden for health care providers or
1189 create barriers to needed care.
1190 Section 13. Except as otherwise expressly provided in this
1191 act, this act shall take effect upon becoming a law.