Florida Senate - 2025 SB 1478
By Senator Rodriguez
40-01148A-25 20251478__
1 A bill to be entitled
2 An act relating to patient referrals by Medicaid
3 managed care organizations and managed care plans;
4 amending s. 409.913, F.S.; authorizing the Agency for
5 Health Care Administration to conduct or cause to be
6 conducted reviews, investigations, analyses, audits,
7 and combinations thereof to determine if managed care
8 organizations, managed care plans, and their
9 subcontractors violate the Medicaid program integrity
10 in their patient referrals; providing penalties;
11 amending s. 409.967, F.S.; prohibiting managed care
12 organizations, managed care plans, and their
13 subcontractors from violating the Medicaid program
14 integrity by referring Medicaid recipients for
15 treatments and services to entities having certain
16 financial relationships and arrangements with the
17 organizations, plans, and their subcontractors;
18 providing an effective date.
19
20 Be It Enacted by the Legislature of the State of Florida:
21
22 Section 1. Subsections (2) and (16) of section 409.913,
23 Florida Statutes, are amended to read:
24 409.913 Oversight of the integrity of the Medicaid
25 program.—The agency shall operate a program to oversee the
26 activities of Florida Medicaid recipients, and providers and
27 their representatives, to ensure that fraudulent and abusive
28 behavior and neglect of recipients occur to the minimum extent
29 possible, and to recover overpayments and impose sanctions as
30 appropriate. Each January 15, the agency and the Medicaid Fraud
31 Control Unit of the Department of Legal Affairs shall submit a
32 report to the Legislature documenting the effectiveness of the
33 state’s efforts to control Medicaid fraud and abuse and to
34 recover Medicaid overpayments during the previous fiscal year.
35 The report must describe the number of cases opened and
36 investigated each year; the sources of the cases opened; the
37 disposition of the cases closed each year; the amount of
38 overpayments alleged in preliminary and final audit letters; the
39 number and amount of fines or penalties imposed; any reductions
40 in overpayment amounts negotiated in settlement agreements or by
41 other means; the amount of final agency determinations of
42 overpayments; the amount deducted from federal claiming as a
43 result of overpayments; the amount of overpayments recovered
44 each year; the amount of cost of investigation recovered each
45 year; the average length of time to collect from the time the
46 case was opened until the overpayment is paid in full; the
47 amount determined as uncollectible and the portion of the
48 uncollectible amount subsequently reclaimed from the Federal
49 Government; the number of providers, by type, that are
50 terminated from participation in the Medicaid program as a
51 result of fraud and abuse; and all costs associated with
52 discovering and prosecuting cases of Medicaid overpayments and
53 making recoveries in such cases. The report must also document
54 actions taken to prevent overpayments and the number of
55 providers prevented from enrolling in or reenrolling in the
56 Medicaid program as a result of documented Medicaid fraud and
57 abuse and must include policy recommendations necessary to
58 prevent or recover overpayments and changes necessary to prevent
59 and detect Medicaid fraud. All policy recommendations in the
60 report must include a detailed fiscal analysis, including, but
61 not limited to, implementation costs, estimated savings to the
62 Medicaid program, and the return on investment. The agency must
63 submit the policy recommendations and fiscal analyses in the
64 report to the appropriate estimating conference, pursuant to s.
65 216.137, by February 15 of each year. The agency and the
66 Medicaid Fraud Control Unit of the Department of Legal Affairs
67 each must include detailed unit-specific performance standards,
68 benchmarks, and metrics in the report, including projected cost
69 savings to the state Medicaid program during the following
70 fiscal year.
71 (2)(a) The agency shall conduct, or cause to be conducted
72 by contract or otherwise, reviews, investigations, analyses,
73 audits, or any combination thereof, to determine possible fraud,
74 abuse, overpayment, or recipient neglect in the Medicaid program
75 and shall report the findings of any overpayments in audit
76 reports as appropriate. At least 5 percent of all audits shall
77 be conducted on a random basis. As part of its ongoing fraud
78 detection activities, the agency shall identify and monitor, by
79 contract or otherwise, patterns of overutilization of Medicaid
80 services based on state averages. The agency shall track
81 Medicaid provider prescription and billing patterns and evaluate
82 them against Medicaid medical necessity criteria and coverage
83 and limitation guidelines adopted by rule. Medical necessity
84 determination requires that service be consistent with symptoms
85 or confirmed diagnosis of illness or injury under treatment and
86 not in excess of the patient’s needs. The agency shall conduct
87 reviews of provider exceptions to peer group norms and shall,
88 using statistical methodologies, provider profiling, and
89 analysis of billing patterns, detect and investigate abnormal or
90 unusual increases in billing or payment of claims for Medicaid
91 services and medically unnecessary provision of services.
92 (b) The agency may conduct, or cause to be conducted by
93 contract or otherwise, reviews, investigations, analyses,
94 audits, or any combination thereof, to determine if a managed
95 care organization or managed care plan or its subcontractor has
96 violated the program integrity under s. 409.967(2)(g)2. by
97 referring a Medicaid recipient for a covered treatment or
98 service rendered by or in the office of a provider, another
99 subcontractor, or a third-party entity that is owned or
100 partially owned by the managed care organization or managed care
101 plan or the subcontractor, or that has a profit-sharing
102 arrangement with the managed care organization or managed care
103 plan or the subcontractor.
104 (16) The agency shall impose any of the following sanctions
105 or disincentives on a provider or a person for any of the acts
106 described in paragraph (2)(b) or subsection (15):
107 (a) Suspension for a specific period of time of not more
108 than 1 year. Suspension precludes participation in the Medicaid
109 program, which includes any action that results in a claim for
110 payment to the Medicaid program for furnishing, supervising a
111 person who is furnishing, or causing a person to furnish goods
112 or services.
113 (b) Termination for a specific period of time ranging from
114 more than 1 year to 20 years. Termination precludes
115 participation in the Medicaid program, which includes any action
116 that results in a claim for payment to the Medicaid program for
117 furnishing, supervising a person who is furnishing, or causing a
118 person to furnish goods or services.
119 (c) Imposition of a fine of up to $5,000 for each
120 violation. Each day that an ongoing violation continues, such as
121 refusing to furnish Medicaid-related records or refusing access
122 to records, is considered a separate violation. Each instance of
123 improper billing of a Medicaid recipient; each instance of
124 including an unallowable cost on a hospital or nursing home
125 Medicaid cost report after the provider or authorized
126 representative has been advised in an audit exit conference or
127 previous audit report of the cost unallowability; each instance
128 of furnishing a Medicaid recipient goods or professional
129 services that are inappropriate or of inferior quality as
130 determined by competent peer judgment; each instance of
131 knowingly submitting a materially false or erroneous Medicaid
132 provider enrollment application, request for prior authorization
133 for Medicaid services, drug exception request, or cost report;
134 each instance of inappropriate prescribing of drugs for a
135 Medicaid recipient as determined by competent peer judgment; and
136 each false or erroneous Medicaid claim leading to an overpayment
137 to a provider is considered a separate violation.
138 (d) Immediate suspension, if the agency has received
139 information of patient abuse or neglect or of any act prohibited
140 by s. 409.920. Upon suspension, the agency must issue an
141 immediate final order under s. 120.569(2)(n).
142 (e) A fine, not to exceed $10,000, for a violation of
143 paragraph (15)(i).
144 (f) Imposition of liens against provider assets, including,
145 but not limited to, financial assets and real property, not to
146 exceed the amount of fines or recoveries sought, upon entry of
147 an order determining that such moneys are due or recoverable.
148 (g) Prepayment reviews of claims for a specified period of
149 time.
150 (h) Comprehensive followup reviews of providers every 6
151 months to ensure that they are billing Medicaid correctly.
152 (i) Corrective action plans that remain in effect for up to
153 3 years and that are monitored by the agency every 6 months
154 while in effect.
155 (j) Other remedies as permitted by law to effect the
156 recovery of a fine or overpayment.
157
158 If a provider voluntarily relinquishes its Medicaid provider
159 number or an associated license, or allows the associated
160 licensure to expire after receiving written notice that the
161 agency is conducting, or has conducted, an audit, survey,
162 inspection, or investigation and that a sanction of suspension
163 or termination will or would be imposed for noncompliance
164 discovered as a result of the audit, survey, inspection, or
165 investigation, the agency shall impose the sanction of
166 termination for cause against the provider. The agency’s
167 termination with cause is subject to hearing rights as may be
168 provided under chapter 120. The Secretary of Health Care
169 Administration may make a determination that imposition of a
170 sanction or disincentive is not in the best interest of the
171 Medicaid program, in which case a sanction or disincentive may
172 not be imposed.
173 Section 2. Paragraph (g) of subsection (2) of section
174 409.967, Florida Statutes, is amended to read:
175 409.967 Managed care plan accountability.—
176 (2) The agency shall establish such contract requirements
177 as are necessary for the operation of the statewide managed care
178 program. In addition to any other provisions the agency may deem
179 necessary, the contract must require:
180 (g) Program integrity.—
181 1. Each managed care plan shall establish program integrity
182 functions and activities to reduce the incidence of fraud and
183 abuse, including, at a minimum:
184 a.1. A provider credentialing system and ongoing provider
185 monitoring, including maintenance of written provider
186 credentialing policies and procedures which comply with federal
187 and agency guidelines;
188 b.2. An effective prepayment and postpayment review process
189 including, but not limited to, data analysis, system editing,
190 and auditing of network providers;
191 c.3. Procedures for reporting instances of fraud and abuse
192 pursuant to chapter 641;
193 d.4. Administrative and management arrangements or
194 procedures, including a mandatory compliance plan, designed to
195 prevent fraud and abuse; and
196 e.5. Designation of a program integrity compliance officer.
197 2. Each managed care organization or managed care plan or
198 its subcontractor may not refer a Medicaid recipient for a
199 covered treatment or service rendered by or in the office of a
200 provider, another subcontractor, or a third-party entity if the
201 managed care organization or managed care plan or its
202 subcontractor has any ownership or profit-sharing arrangement
203 with the provider, the other subcontractor, or the third-party
204 entity.
205 Section 3. This act shall take effect July 1, 2025.