November 15, 2019
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       CS for CS for CS for SB 752                      First Engrossed
       
       
       
       
       
       
       
       
       2010752e1
       
    1                        A bill to be entitled                      
    2         An act relating to health care; amending s. 400.471,
    3         F.S.; prohibiting the Agency for Health Care
    4         Administration from issuing an initial license to a
    5         home health agency for the purpose of opening a new
    6         home health agency under certain conditions until a
    7         specified date; prohibiting the agency from issuing a
    8         change-of-ownership license to a home health agency
    9         under certain conditions until a specified date;
   10         providing an exception; amending s. 400.474, F.S.;
   11         authorizing the agency to revoke a home health agency
   12         license if the applicant or any controlling interest
   13         has been sanctioned for acts specified under s.
   14         400.471(10), F.S.; amending s. 400.9905, F.S.;
   15         specifying that certain licensure requirements do not
   16         apply to certain pediatric cardiological or
   17         perinatological clinical facilities; providing that
   18         part X of ch. 400, F.S., the Health Care Clinic Act,
   19         does not apply to entities owned by a corporation that
   20         has a specified amount of annual sales of health care
   21         services under certain circumstances; amending s.
   22         408.815, F.S.; revising the grounds upon which the
   23         agency may deny or revoke an application for an
   24         initial license, a change-of-ownership license, or a
   25         licensure renewal for certain health care entities
   26         listed in s. 408.802, F.S.; amending s. 408.910, F.S.;
   27         revising the list of employers who are eligible to
   28         enroll in the Florida Health Choices Program; revising
   29         the membership of the board of directors of the
   30         Florida Health Choices, Inc.; requiring the President
   31         of the Senate and the Speaker of the House of
   32         Representatives to initially appoint members to the
   33         board of directors for staggered terms; requiring that
   34         the members of the board appoint new members to the
   35         board of directors after a specified date, subject to
   36         Senate confirmation; deleting a provision that
   37         prohibits board members from serving for more than a
   38         certain number of consecutive years; amending s.
   39         409.907, F.S.; extending the number of years that
   40         Medicaid providers must retain Medicaid recipient
   41         records; adding additional requirements to the
   42         Medicaid provider agreement; revising applicability of
   43         screening requirements; revising conditions under
   44         which the agency is authorized to deny a Medicaid
   45         provider application; amending s. 409.912, F.S.;
   46         revising requirements for Medicaid prepaid, fixed-sum,
   47         and managed care contracts; revising requirements for
   48         Medicaid durable medical equipment providers;
   49         repealing s. 409.9122(13), F.S., relating to the
   50         enrollee assignment process of Medicaid managed
   51         prepaid health plans for those Medicaid managed
   52         prepaid health plans operating in Miami-Dade County;
   53         amending s. 409.913, F.S.; removing a required element
   54         from the joint Medicaid fraud and abuse report
   55         submitted by the agency and the Medicaid Fraud Control
   56         Unit of the Department of Legal Affairs; extending the
   57         number of years that Medicaid providers must retain
   58         Medicaid recipient records; authorizing the Medicaid
   59         program integrity staff to immediately suspend or
   60         terminate a Medicaid provider for engaging in
   61         specified conduct; removing a requirement for the
   62         agency to hold suspended Medicaid payments in a
   63         separate account; authorizing the agency to deny
   64         payment or require repayment to Medicaid providers
   65         convicted of certain crimes; authorizing the agency to
   66         terminate a Medicaid provider if the provider fails to
   67         reimburse a fine determined by a final order;
   68         authorizing the agency to withhold Medicaid
   69         reimbursement to a Medicaid provider that fails to pay
   70         a fine determined by a final order, fails to enter
   71         into a repayment plan, or fails to comply with a
   72         repayment plan or settlement agreement; requiring the
   73         biennial review of Medicaid fraud and abuse by the
   74         Office of Program Policy Analysis and Government
   75         Accountability to include a report on the Medicaid
   76         Fraud Control Unit within the Department of Legal
   77         Affairs; amending s. 409.9203, F.S.; providing that
   78         certain state employees are ineligible from receiving
   79         a reward for reporting Medicaid fraud; amending s.
   80         456.001, F.S.; defining the term “affiliate” or
   81         “affiliated person” as it relates to health
   82         professions and occupations; amending s. 456.041,
   83         F.S.; requiring the Department of Health to include
   84         administrative complaints and any conviction
   85         information relating to the practitioner’s profile;
   86         providing a disclaimer; amending s. 456.0635, F.S.;
   87         revising the grounds under which the Department of
   88         Health or corresponding board is required to refuse to
   89         admit a candidate to an examination and refuse to
   90         issue or renew a license, certificate, or registration
   91         of a health care practitioner; providing an exception;
   92         amending s. 456.072, F.S.; clarifying a ground under
   93         which disciplinary actions may be taken; amending s.
   94         456.073, F.S.; revising applicability of
   95         investigations and administrative complaints to
   96         include Medicaid fraud; amending s. 456.074, F.S.;
   97         authorizing the Department of Health to issue an
   98         emergency order suspending the license of any person
   99         licensed under ch. 456, F.S., who engages in specified
  100         criminal conduct; amending s. 499.01, F.S.; exempting
  101         certain persons from requirements for medical device
  102         manufacturer permits; providing an effective date.
  103  
  104  Be It Enacted by the Legislature of the State of Florida:
  105  
  106         Section 1. Subsection (11) of section 400.471, Florida
  107  Statutes, is amended to read:
  108         400.471 Application for license; fee.—
  109         (11)(a) The agency may not issue an initial license to a
  110  home health agency under part II of chapter 408 or this part for
  111  the purpose of opening a new home health agency until July 1,
  112  2012 2010, in any county that has at least one actively licensed
  113  home health agency and a population of persons 65 years of age
  114  or older, as indicated in the most recent population estimates
  115  published by the Executive Office of the Governor, of fewer than
  116  1,200 per home health agency. In such counties, for any
  117  application received by the agency prior to July 1, 2009, which
  118  has been deemed by the agency to be complete except for proof of
  119  accreditation, the agency may issue an initial ownership license
  120  only if the applicant has applied for accreditation before May
  121  1, 2009, from an accrediting organization that is recognized by
  122  the agency.
  123         (b) Effective October 1, 2009, the agency may not issue a
  124  change of ownership license to a home health agency under part
  125  II of chapter 408 or this part until July 1, 2012 2010, in any
  126  county that has at least one actively licensed home health
  127  agency and a population of persons 65 years of age or older, as
  128  indicated in the most recent population estimates published by
  129  the Executive Office of the Governor, of fewer than 1,200 per
  130  home health agency. In such counties, for any application
  131  received by the agency before prior to October 1, 2009, which
  132  has been deemed by the agency to be complete except for proof of
  133  accreditation, the agency may issue a change of ownership
  134  license only if the applicant has applied for accreditation
  135  before August 1, 2009, from an accrediting organization that is
  136  recognized by the agency. This paragraph does not apply to an
  137  application for a change in ownership from an existing home
  138  health agency that is accredited, has been licensed by the state
  139  at least 5 years, and is in good standing with the agency.
  140         Section 2. Subsection (8) is added to section 400.474,
  141  Florida Statutes, to read:
  142         400.474 Administrative penalties.—
  143         (8)The agency may revoke the license of a home health
  144  agency that is not eligible for licensure renewal under s.
  145  400.471(10).
  146         Section 3. Paragraph (l) of subsection (4) of section
  147  400.9905, Florida Statutes, is amended, and paragraph (m) is
  148  added to that subsection, to read:
  149         400.9905 Definitions.—
  150         (4) “Clinic” means an entity at which health care services
  151  are provided to individuals and which tenders charges for
  152  reimbursement for such services, including a mobile clinic and a
  153  portable equipment provider. For purposes of this part, the term
  154  does not include and the licensure requirements of this part do
  155  not apply to:
  156         (l) Orthotic, or prosthetic, pediatric cardiological, or
  157  perinatological clinical facilities that are a publicly traded
  158  corporation or that are wholly owned, directly or indirectly, by
  159  a publicly traded corporation. As used in this paragraph, a
  160  publicly traded corporation is a corporation that issues
  161  securities traded on an exchange registered with the United
  162  States Securities and Exchange Commission as a national
  163  securities exchange.
  164         (m) Entities that are owned by a corporation that has $250
  165  million or more in total annual sales of health care services
  166  provided by licensed health care practitioners if one or more of
  167  the owners of the entity is a health care practitioner who is
  168  licensed in this state, is responsible for supervising the
  169  business activities of the entity, and is legally responsible
  170  for the entity’s compliance with state law for purposes of this
  171  section.
  172         Section 4. Subsections (1) and (4) of section 408.815,
  173  Florida Statutes, are amended, and subsection (5) is added to
  174  that section, to read:
  175         408.815 License or application denial; revocation.—
  176         (1) In addition to the grounds provided in authorizing
  177  statutes, grounds that may be used by the agency for denying and
  178  revoking a license or change of ownership application include
  179  any of the following actions by a controlling interest:
  180         (a) False representation of a material fact in the license
  181  application or omission of any material fact from the
  182  application.
  183         (b) An intentional or negligent act materially affecting
  184  the health or safety of a client of the provider.
  185         (c) A violation of this part, authorizing statutes, or
  186  applicable rules.
  187         (d) A demonstrated pattern of deficient performance.
  188         (e) The applicant, licensee, or controlling interest has
  189  been or is currently excluded, suspended, or terminated from
  190  participation in the state Medicaid program, the Medicaid
  191  program of any other state, or the Medicare program.
  192         (f) The applicant, licensee, or controlling interest is or
  193  was an administrator or controlling interest in a facility or
  194  entity during the period an event that caused or contributed to
  195  the facility or entity being excluded, suspended, or terminated
  196  from participation in the state Medicaid program, the Medicaid
  197  program of any other state, or the Medicare program.
  198         (4) In addition to the grounds provided in authorizing
  199  statutes, the agency shall deny an application for an initial a
  200  license or a change-of-ownership license renewal if the
  201  applicant or a person having a controlling interest in the an
  202  applicant has been:
  203         (a) Has been convicted of, or entered enters a plea of
  204  guilty or nolo contendere to, regardless of adjudication, a
  205  felony under chapter 409, chapter 817, chapter 893, or a similar
  206  felony offense committed in another state or jurisdiction 21
  207  U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the
  208  sentence and any subsequent period of probation for such
  209  conviction convictions or plea ended more than 15 years before
  210  prior to the date of the application;
  211         (b)Has been convicted of, or entered a plea of guilty or
  212  nolo contendere to, regardless of adjudication, a felony under
  213  21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the
  214  sentence and any subsequent period of probation for such
  215  conviction or plea ended more than 15 years before the date of
  216  the application;
  217         (c)(b)Has been terminated for cause from the Florida
  218  Medicaid program pursuant to s. 409.913, unless the applicant
  219  has been in good standing with the Florida Medicaid program for
  220  the most recent 5 years; or
  221         (d)(c)Has been terminated for cause, pursuant to the
  222  appeals procedures established by the state, or Federal
  223  Government, from the federal Medicare program or from any other
  224  state Medicaid program, unless the applicant has been in good
  225  standing with a state Medicaid program or the federal Medicare
  226  program for the most recent 5 years and the termination occurred
  227  at least 20 years before prior to the date of the application;
  228  or.
  229         (e)Is currently listed on the United States Department of
  230  Health and Human Services Office of Inspector General’s List of
  231  Excluded Individuals and Entities.
  232         (5)In addition to the grounds provided in authorizing
  233  statutes, the agency shall deny an application for licensure
  234  renewal if the applicant or a person having a controlling
  235  interest in the applicant:
  236         (a)Has been convicted of, or entered a plea of guilty or
  237  nolo contendere to, regardless of adjudication, a felony under
  238  chapter 409, chapter 817, chapter 893, or a similar felony
  239  offense committed in another state or jurisdiction since July 1,
  240  2009;
  241         (b)Has been convicted of, or entered a plea of guilty or
  242  nolo contendere to, regardless of adjudication, a felony under
  243  21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396 since July 1,
  244  2009;
  245         (c)Has been terminated for cause from the Florida Medicaid
  246  program pursuant to s. 409.913, unless the applicant has been in
  247  good standing with the Florida Medicaid program for the most
  248  recent 5 years;
  249         (d)Has been terminated for cause, pursuant to the appeals
  250  procedures established by the state, from any other state
  251  Medicaid program, unless the applicant has been in good standing
  252  with a state Medicaid program for the most recent 5 years and
  253  the termination occurred at least 20 years before the date of
  254  the application; or
  255         (e)Is currently listed on the United States Department of
  256  Health and Human Services Office of Inspector General’s List of
  257  Excluded Individuals and Entities.
  258         Section 5. Paragraph (a) of subsection (4) and subsection
  259  (11) of section 408.910, Florida Statutes, are amended to read:
  260         408.910 Florida Health Choices Program.—
  261         (4) ELIGIBILITY AND PARTICIPATION.—Participation in the
  262  program is voluntary and shall be available to employers,
  263  individuals, vendors, and health insurance agents as specified
  264  in this subsection.
  265         (a) Employers eligible to enroll in the program include:
  266         1. Employers that have 1 to 50 employees.
  267         2. Fiscally constrained counties described in s. 218.67.
  268         3. Municipalities having populations of fewer than 50,000
  269  residents.
  270         4. School districts in fiscally constrained counties.
  271         5. State universities and community colleges.
  272         (11) CORPORATION.—There is created the Florida Health
  273  Choices, Inc., which shall be registered, incorporated,
  274  organized, and operated in compliance with part III of chapter
  275  112 and chapters 119, 286, and 617. The purpose of the
  276  corporation is to administer the program created in this section
  277  and to conduct such other business as may further the
  278  administration of the program.
  279         (a)1. The corporation shall be governed by a five-member
  280  15-member board of directors consisting of:
  281         1.Three ex officio, nonvoting members to include:
  282         a.The Secretary of Health Care Administration or a
  283  designee with expertise in health care services.
  284         b.The Secretary of Management Services or a designee with
  285  expertise in state employee benefits.
  286         c.The commissioner of the Office of Insurance Regulation
  287  or a designee with expertise in insurance regulation.
  288         a.2.One member Four members appointed by and serving at
  289  the pleasure of the Governor.
  290         b.3.Two Four members appointed by and serving at the
  291  pleasure of the President of the Senate.
  292         c.4.Two Four members appointed by and serving at the
  293  pleasure of the Speaker of the House of Representatives.
  294         2.5. Board members may not include insurers, health
  295  insurance agents or brokers, health care providers, health
  296  maintenance organizations, prepaid service providers, or any
  297  other entity, affiliate or subsidiary of eligible vendors.
  298         (b)1. Members shall be appointed for terms of up to 4 3
  299  years. In order to establish staggered terms, for the initial
  300  appointments the President of the Senate and the Speaker of the
  301  House of Representatives shall each appoint one member to a 2
  302  year term and one member to a 4-year term. Any member is
  303  eligible for reappointment. A vacancy on the board shall be
  304  filled for the unexpired portion of the term in the same manner
  305  as the original appointment.
  306         2. Beginning July 1, 2011, the members of the board of
  307  directors shall appoint new members to the board of directors,
  308  subject to confirmation by the Senate.
  309         (c) The board shall select a chief executive officer for
  310  the corporation who shall be responsible for the selection of
  311  such other staff as may be authorized by the corporation’s
  312  operating budget as adopted by the board.
  313         (d) Board members are entitled to receive, from funds of
  314  the corporation, reimbursement for per diem and travel expenses
  315  as provided by s. 112.061. No other compensation is authorized.
  316         (e) There is no liability on the part of, and no cause of
  317  action shall arise against, any member of the board or its
  318  employees or agents for any action taken by them in the
  319  performance of their powers and duties under this section.
  320         (f) The board shall develop and adopt bylaws and other
  321  corporate procedures as necessary for the operation of the
  322  corporation and carrying out the purposes of this section. The
  323  bylaws shall:
  324         1. Specify procedures for selection of officers and
  325  qualifications for reappointment, provided that no board member
  326  shall serve more than 9 consecutive years.
  327         2. Require an annual membership meeting that provides an
  328  opportunity for input and interaction with individual
  329  participants in the program.
  330         3. Specify policies and procedures regarding conflicts of
  331  interest, including the provisions of part III of chapter 112,
  332  which prohibit a member from participating in any decision that
  333  would inure to the benefit of the member or the organization
  334  that employs the member. The policies and procedures shall also
  335  require public disclosure of the interest that prevents the
  336  member from participating in a decision on a particular matter.
  337         (g) The corporation may exercise all powers granted to it
  338  under chapter 617 necessary to carry out the purposes of this
  339  section, including, but not limited to, the power to receive and
  340  accept grants, loans, or advances of funds from any public or
  341  private agency and to receive and accept from any source
  342  contributions of money, property, labor, or any other thing of
  343  value to be held, used, and applied for the purposes of this
  344  section.
  345         (h) The corporation may establish technical advisory panels
  346  consisting of interested parties, including consumers, health
  347  care providers, individuals with expertise in insurance
  348  regulation, and insurers.
  349         (i) The corporation shall:
  350         1. Determine eligibility of employers, vendors,
  351  individuals, and agents in accordance with subsection (4).
  352         2. Establish procedures necessary for the operation of the
  353  program, including, but not limited to, procedures for
  354  application, enrollment, risk assessment, risk adjustment, plan
  355  administration, performance monitoring, and consumer education.
  356         3. Arrange for collection of contributions from
  357  participating employers and individuals.
  358         4. Arrange for payment of premiums and other appropriate
  359  disbursements based on the selections of products and services
  360  by the individual participants.
  361         5. Establish criteria for disenrollment of participating
  362  individuals based on failure to pay the individual’s share of
  363  any contribution required to maintain enrollment in selected
  364  products.
  365         6. Establish criteria for exclusion of vendors pursuant to
  366  paragraph (4)(d).
  367         7. Develop and implement a plan for promoting public
  368  awareness of and participation in the program.
  369         8. Secure staff and consultant services necessary to the
  370  operation of the program.
  371         9. Establish policies and procedures regarding
  372  participation in the program for individuals, vendors, health
  373  insurance agents, and employers.
  374         10. Develop a plan, in coordination with the Department of
  375  Revenue, to establish tax credits or refunds for employers that
  376  participate in the program. The corporation shall submit the
  377  plan to the Governor, the President of the Senate, and the
  378  Speaker of the House of Representatives by January 1, 2009.
  379         Section 6. Paragraph (c) of subsection (3) of section
  380  409.907, Florida Statutes, is amended, paragraph (k) is added to
  381  that subsection, and subsection (8), paragraph (b) of subsection
  382  (9), and subsection (10) of that section are amended, to read:
  383         409.907 Medicaid provider agreements.—The agency may make
  384  payments for medical assistance and related services rendered to
  385  Medicaid recipients only to an individual or entity who has a
  386  provider agreement in effect with the agency, who is performing
  387  services or supplying goods in accordance with federal, state,
  388  and local law, and who agrees that no person shall, on the
  389  grounds of handicap, race, color, or national origin, or for any
  390  other reason, be subjected to discrimination under any program
  391  or activity for which the provider receives payment from the
  392  agency.
  393         (3) The provider agreement developed by the agency, in
  394  addition to the requirements specified in subsections (1) and
  395  (2), shall require the provider to:
  396         (c) Retain all medical and Medicaid-related records for a
  397  period of 6 5 years to satisfy all necessary inquiries by the
  398  agency.
  399         (k)Report any change of any principal of the provider,
  400  including any officer, director, agent, managing employee, or
  401  affiliated person, or any partner or shareholder who has an
  402  ownership interest equal to 5 percent or more in the provider.
  403  The provider must report changes to the agency no later than 30
  404  days after the change occurs. Reporting changes in controlling
  405  interests to the agency pursuant to s. 408.810(3) shall serve as
  406  compliance with this paragraph for hospitals licensed under
  407  chapter 395 and nursing homes licensed under chapter 400.
  408         (8)(a) Each provider, or each principal of the provider if
  409  the provider is a corporation, partnership, association, or
  410  other entity, seeking to participate in the Medicaid program
  411  must submit a complete set of his or her fingerprints to the
  412  agency for the purpose of conducting a criminal history record
  413  check. Principals of the provider include any officer, director,
  414  billing agent, managing employee, or affiliated person, or any
  415  partner or shareholder who has an ownership interest equal to 5
  416  percent or more in the provider. However, for hospitals licensed
  417  under chapter 395 and nursing homes licensed under chapter 400,
  418  principals of the provider are those who meet the definition of
  419  a controlling interest in s. 408.803(7). A director of a not
  420  for-profit corporation or organization is not a principal for
  421  purposes of a background investigation as required by this
  422  section if the director: serves solely in a voluntary capacity
  423  for the corporation or organization, does not regularly take
  424  part in the day-to-day operational decisions of the corporation
  425  or organization, receives no remuneration from the not-for
  426  profit corporation or organization for his or her service on the
  427  board of directors, has no financial interest in the not-for
  428  profit corporation or organization, and has no family members
  429  with a financial interest in the not-for-profit corporation or
  430  organization; and if the director submits an affidavit, under
  431  penalty of perjury, to this effect to the agency and the not
  432  for-profit corporation or organization submits an affidavit,
  433  under penalty of perjury, to this effect to the agency as part
  434  of the corporation’s or organization’s Medicaid provider
  435  agreement application. Notwithstanding the above, the agency may
  436  require a background check for any person reasonably suspected
  437  by the agency to have been convicted of a crime. This subsection
  438  does shall not apply to:
  439         1.A hospital licensed under chapter 395;
  440         2.A nursing home licensed under chapter 400;
  441         3.A hospice licensed under chapter 400;
  442         4.An assisted living facility licensed under chapter 429;
  443         1.5. A unit of local government, except that requirements
  444  of this subsection apply to nongovernmental providers and
  445  entities when contracting with the local government to provide
  446  Medicaid services. The actual cost of the state and national
  447  criminal history record checks must be borne by the
  448  nongovernmental provider or entity; or
  449         2.6. Any business that derives more than 50 percent of its
  450  revenue from the sale of goods to the final consumer, and the
  451  business or its controlling parent either is required to file a
  452  form 10-K or other similar statement with the Securities and
  453  Exchange Commission or has a net worth of $50 million or more.
  454         (b) Background screening shall be conducted in accordance
  455  with chapter 435 and s. 408.809. The agency shall submit the
  456  fingerprints to the Department of Law Enforcement. The
  457  department shall conduct a state criminal-background
  458  investigation and forward the fingerprints to the Federal Bureau
  459  of Investigation for a national criminal-history record check.
  460  The cost of the state and national criminal record check shall
  461  be borne by the provider.
  462         (c)The agency may permit a provider to participate in the
  463  Medicaid program pending the results of the criminal record
  464  check. However, such permission is fully revocable if the record
  465  check reveals any crime-related history as provided in
  466  subsection (10).
  467         (c)(d) Proof of compliance with the requirements of level 2
  468  screening under s. 435.04 conducted within 12 months prior to
  469  the date that the Medicaid provider application is submitted to
  470  the agency shall fulfill the requirements of this subsection.
  471  Proof of compliance with the requirements of level 1 screening
  472  under s. 435.03 conducted within 12 months prior to the date
  473  that the Medicaid provider application is submitted to the
  474  agency shall meet the requirement that the Department of Law
  475  Enforcement conduct a state criminal history record check.
  476         (9) Upon receipt of a completed, signed, and dated
  477  application, and completion of any necessary background
  478  investigation and criminal history record check, the agency must
  479  either:
  480         (b) Deny the application if the agency finds that it is in
  481  the best interest of the Medicaid program to do so. The agency
  482  may consider any the factors listed in subsection (10), as well
  483  as any other factor that could affect the effective and
  484  efficient administration of the program, including, but not
  485  limited to, the applicant’s demonstrated ability to provide
  486  services, conduct business, and operate a financially viable
  487  concern; the current availability of medical care, services, or
  488  supplies to recipients, taking into account geographic location
  489  and reasonable travel time; the number of providers of the same
  490  type already enrolled in the same geographic area; and the
  491  credentials, experience, success, and patient outcomes of the
  492  provider for the services that it is making application to
  493  provide in the Medicaid program. The agency shall deny the
  494  application if the agency finds that a provider; any officer,
  495  director, agent, managing employee, or affiliated person; or any
  496  principal, partner, or shareholder having an ownership interest
  497  equal to 5 percent or greater in the provider if the provider is
  498  a corporation, partnership, or other business entity, has failed
  499  to pay all outstanding fines or overpayments assessed by final
  500  order of the agency or final order of the Centers for Medicare
  501  and Medicaid Services, not subject to further appeal, unless the
  502  provider agrees to a repayment plan that includes withholding
  503  Medicaid reimbursement until the amount due is paid in full.
  504         (10) The agency shall deny the application if may consider
  505  whether the provider, or any officer, director, agent, managing
  506  employee, or affiliated person, or any principal, partner, or
  507  shareholder having an ownership interest equal to 5 percent or
  508  greater in the provider if the provider is a corporation,
  509  partnership, or other business entity, has committed an offense
  510  listed in s. 409.913(13), and may deny the application if one of
  511  these persons has:
  512         (a) Made a false representation or omission of any material
  513  fact in making the application, including the submission of an
  514  application that conceals the controlling or ownership interest
  515  of any officer, director, agent, managing employee, affiliated
  516  person, or principal, partner, or shareholder who may not be
  517  eligible to participate;
  518         (b) Been or is currently excluded, suspended, terminated
  519  from, or has involuntarily withdrawn from participation in,
  520  Florida’s Medicaid program or any other state’s Medicaid
  521  program, or from participation in any other governmental or
  522  private health care or health insurance program;
  523         (c)Been convicted of a criminal offense relating to the
  524  delivery of any goods or services under Medicaid or Medicare or
  525  any other public or private health care or health insurance
  526  program including the performance of management or
  527  administrative services relating to the delivery of goods or
  528  services under any such program;
  529         (d)Been convicted under federal or state law of a criminal
  530  offense related to the neglect or abuse of a patient in
  531  connection with the delivery of any health care goods or
  532  services;
  533         (c)(e) Been convicted under federal or state law of a
  534  criminal offense relating to the unlawful manufacture,
  535  distribution, prescription, or dispensing of a controlled
  536  substance;
  537         (d)(f) Been convicted of any criminal offense relating to
  538  fraud, theft, embezzlement, breach of fiduciary responsibility,
  539  or other financial misconduct;
  540         (e)(g) Been convicted under federal or state law of a crime
  541  punishable by imprisonment of a year or more which involves
  542  moral turpitude;
  543         (f)(h) Been convicted in connection with the interference
  544  or obstruction of any investigation into any criminal offense
  545  listed in this subsection;
  546         (g)(i) Been found to have violated federal or state laws,
  547  rules, or regulations governing Florida’s Medicaid program or
  548  any other state’s Medicaid program, the Medicare program, or any
  549  other publicly funded federal or state health care or health
  550  insurance program, and been sanctioned accordingly;
  551         (h)(j) Been previously found by a licensing, certifying, or
  552  professional standards board or agency to have violated the
  553  standards or conditions relating to licensure or certification
  554  or the quality of services provided; or
  555         (i)(k) Failed to pay any fine or overpayment properly
  556  assessed under the Medicaid program in which no appeal is
  557  pending or after resolution of the proceeding by stipulation or
  558  agreement, unless the agency has issued a specific letter of
  559  forgiveness or has approved a repayment schedule to which the
  560  provider agrees to adhere.
  561  
  562  If the agency determines a provider did not participate or
  563  acquiesce in an offense specified in s. 409.913(13), the agency
  564  is not required to deny the provider application.
  565         Section 7. Subsections (10), (32), and (48) of section
  566  409.912, Florida Statutes, are amended to read:
  567         409.912 Cost-effective purchasing of health care.—The
  568  agency shall purchase goods and services for Medicaid recipients
  569  in the most cost-effective manner consistent with the delivery
  570  of quality medical care. To ensure that medical services are
  571  effectively utilized, the agency may, in any case, require a
  572  confirmation or second physician’s opinion of the correct
  573  diagnosis for purposes of authorizing future services under the
  574  Medicaid program. This section does not restrict access to
  575  emergency services or poststabilization care services as defined
  576  in 42 C.F.R. part 438.114. Such confirmation or second opinion
  577  shall be rendered in a manner approved by the agency. The agency
  578  shall maximize the use of prepaid per capita and prepaid
  579  aggregate fixed-sum basis services when appropriate and other
  580  alternative service delivery and reimbursement methodologies,
  581  including competitive bidding pursuant to s. 287.057, designed
  582  to facilitate the cost-effective purchase of a case-managed
  583  continuum of care. The agency shall also require providers to
  584  minimize the exposure of recipients to the need for acute
  585  inpatient, custodial, and other institutional care and the
  586  inappropriate or unnecessary use of high-cost services. The
  587  agency shall contract with a vendor to monitor and evaluate the
  588  clinical practice patterns of providers in order to identify
  589  trends that are outside the normal practice patterns of a
  590  provider’s professional peers or the national guidelines of a
  591  provider’s professional association. The vendor must be able to
  592  provide information and counseling to a provider whose practice
  593  patterns are outside the norms, in consultation with the agency,
  594  to improve patient care and reduce inappropriate utilization.
  595  The agency may mandate prior authorization, drug therapy
  596  management, or disease management participation for certain
  597  populations of Medicaid beneficiaries, certain drug classes, or
  598  particular drugs to prevent fraud, abuse, overuse, and possible
  599  dangerous drug interactions. The Pharmaceutical and Therapeutics
  600  Committee shall make recommendations to the agency on drugs for
  601  which prior authorization is required. The agency shall inform
  602  the Pharmaceutical and Therapeutics Committee of its decisions
  603  regarding drugs subject to prior authorization. The agency is
  604  authorized to limit the entities it contracts with or enrolls as
  605  Medicaid providers by developing a provider network through
  606  provider credentialing. The agency may competitively bid single
  607  source-provider contracts if procurement of goods or services
  608  results in demonstrated cost savings to the state without
  609  limiting access to care. The agency may limit its network based
  610  on the assessment of beneficiary access to care, provider
  611  availability, provider quality standards, time and distance
  612  standards for access to care, the cultural competence of the
  613  provider network, demographic characteristics of Medicaid
  614  beneficiaries, practice and provider-to-beneficiary standards,
  615  appointment wait times, beneficiary use of services, provider
  616  turnover, provider profiling, provider licensure history,
  617  previous program integrity investigations and findings, peer
  618  review, provider Medicaid policy and billing compliance records,
  619  clinical and medical record audits, and other factors. Providers
  620  shall not be entitled to enrollment in the Medicaid provider
  621  network. The agency shall determine instances in which allowing
  622  Medicaid beneficiaries to purchase durable medical equipment and
  623  other goods is less expensive to the Medicaid program than long
  624  term rental of the equipment or goods. The agency may establish
  625  rules to facilitate purchases in lieu of long-term rentals in
  626  order to protect against fraud and abuse in the Medicaid program
  627  as defined in s. 409.913. The agency may seek federal waivers
  628  necessary to administer these policies.
  629         (10) The agency shall not contract on a prepaid or fixed
  630  sum basis for Medicaid services with an entity which knows or
  631  reasonably should know that any principal, officer, director,
  632  agent, managing employee, or owner of stock or beneficial
  633  interest in excess of 5 percent common or preferred stock, or
  634  the entity itself, has been found guilty of, regardless of
  635  adjudication, or entered a plea of nolo contendere, or guilty,
  636  to:
  637         (a) An offense listed in s. 408.809, s. 409.913(13), or s.
  638  435.04 Fraud;
  639         (b) Violation of federal or state antitrust statutes,
  640  including those proscribing price fixing between competitors and
  641  the allocation of customers among competitors;
  642         (c) Commission of a felony involving embezzlement, theft,
  643  forgery, income tax evasion, bribery, falsification or
  644  destruction of records, making false statements, receiving
  645  stolen property, making false claims, or obstruction of justice;
  646  or
  647         (d) Any crime in any jurisdiction which directly relates to
  648  the provision of health services on a prepaid or fixed-sum
  649  basis.
  650         (32) Each managed care plan that is under contract with the
  651  agency to provide health care services to Medicaid recipients
  652  shall annually conduct a background check with the Florida
  653  Department of Law Enforcement of all persons with ownership
  654  interest of 5 percent or more or executive management
  655  responsibility for the managed care plan and shall submit to the
  656  agency information concerning any such person who has been found
  657  guilty of, regardless of adjudication, or has entered a plea of
  658  nolo contendere or guilty to, any of the offenses listed in s.
  659  408.809, s. 409.913(13), or s. 435.04 s. 435.03.
  660         (48)(a) A provider is not entitled to enrollment in the
  661  Medicaid provider network. The agency may implement a Medicaid
  662  fee-for-service provider network controls, including, but not
  663  limited to, competitive procurement and provider credentialing.
  664  If a credentialing process is used, the agency may limit its
  665  provider network based upon the following considerations:
  666  beneficiary access to care, provider availability, provider
  667  quality standards and quality assurance processes, cultural
  668  competency, demographic characteristics of beneficiaries,
  669  practice standards, service wait times, provider turnover,
  670  provider licensure and accreditation history, program integrity
  671  history, peer review, Medicaid policy and billing compliance
  672  records, clinical and medical record audit findings, and such
  673  other areas that are considered necessary by the agency to
  674  ensure the integrity of the program.
  675         (b) The agency shall limit its network of durable medical
  676  equipment and medical supply providers. For dates of service
  677  after January 1, 2009, the agency shall limit payment for
  678  durable medical equipment and supplies to providers that meet
  679  all the requirements of this paragraph.
  680         1. Providers must be accredited by a Centers for Medicare
  681  and Medicaid Services deemed accreditation organization for
  682  suppliers of durable medical equipment, prosthetics, orthotics,
  683  and supplies. The provider must maintain accreditation and is
  684  subject to unannounced reviews by the accrediting organization.
  685         2. Providers must provide the services or supplies directly
  686  to the Medicaid recipient or caregiver at the provider location
  687  or recipient’s residence or send the supplies directly to the
  688  recipient’s residence with receipt of mailed delivery.
  689  Subcontracting or consignment of the service or supply to a
  690  third party is prohibited.
  691         3. Notwithstanding subparagraph 2., a durable medical
  692  equipment provider may store nebulizers at a physician’s office
  693  for the purpose of having the physician’s staff issue the
  694  equipment if it meets all of the following conditions:
  695         a. The physician must document the medical necessity and
  696  need to prevent further deterioration of the patient’s
  697  respiratory status by the timely delivery of the nebulizer in
  698  the physician’s office.
  699         b. The durable medical equipment provider must have written
  700  documentation of the competency and training by a Florida
  701  licensed registered respiratory therapist of any durable medical
  702  equipment staff who participate in the training of physician
  703  office staff for the use of nebulizers, including cleaning,
  704  warranty, and special needs of patients.
  705         c. The physician’s office must have documented the training
  706  and competency of any staff member who initiates the delivery of
  707  nebulizers to patients. The durable medical equipment provider
  708  must maintain copies of all physician office training.
  709         d. The physician’s office must maintain inventory records
  710  of stored nebulizers, including documentation of the durable
  711  medical equipment provider source.
  712         e. A physician contracted with a Medicaid durable medical
  713  equipment provider may not have a financial relationship with
  714  that provider or receive any financial gain from the delivery of
  715  nebulizers to patients.
  716         4. Providers must have a physical business location and a
  717  functional landline business phone. The location must be within
  718  the state or not more than 50 miles from the Florida state line.
  719  The agency may make exceptions for providers of durable medical
  720  equipment or supplies not otherwise available from other
  721  enrolled providers located within the state.
  722         5. Physical business locations must be clearly identified
  723  as a business that furnishes durable medical equipment or
  724  medical supplies by signage that can be read from 20 feet away.
  725  The location must be readily accessible to the public during
  726  normal, posted business hours and must operate no less than 5
  727  hours per day and no less than 5 days per week, with the
  728  exception of scheduled and posted holidays. The location may not
  729  be located within or at the same numbered street address as
  730  another enrolled Medicaid durable medical equipment or medical
  731  supply provider or as an enrolled Medicaid pharmacy that is also
  732  enrolled as a durable medical equipment provider. A licensed
  733  orthotist or prosthetist that provides only orthotic or
  734  prosthetic devices as a Medicaid durable medical equipment
  735  provider is exempt from the provisions in this paragraph.
  736         6. Providers must maintain a stock of durable medical
  737  equipment and medical supplies on site that is readily available
  738  to meet the needs of the durable medical equipment business
  739  location’s customers.
  740         7. Providers must provide a surety bond of $50,000 for each
  741  provider location, up to a maximum of 5 bonds statewide or an
  742  aggregate bond of $250,000 statewide, as identified by Federal
  743  Employer Identification Number. Providers who post a statewide
  744  or an aggregate bond must identify all of their locations in any
  745  Medicaid durable medical equipment and medical supply provider
  746  enrollment application or bond renewal. Each provider location’s
  747  surety bond must be renewed annually and the provider must
  748  submit proof of renewal even if the original bond is a
  749  continuous bond. A licensed orthotist or prosthetist that
  750  provides only orthotic or prosthetic devices as a Medicaid
  751  durable medical equipment provider is exempt from the provisions
  752  in this paragraph.
  753         8. Providers must obtain a level 2 background screening, in
  754  accordance with chapter 435 and s. 408.809 as provided under s.
  755  435.04, for each provider employee in direct contact with or
  756  providing direct services to recipients of durable medical
  757  equipment and medical supplies in their homes. This requirement
  758  includes, but is not limited to, repair and service technicians,
  759  fitters, and delivery staff. The provider shall pay for the cost
  760  of the background screening.
  761         9. The following providers are exempt from the requirements
  762  of subparagraphs 1. and 7.:
  763         a. Durable medical equipment providers owned and operated
  764  by a government entity.
  765         b. Durable medical equipment providers that are operating
  766  within a pharmacy that is currently enrolled as a Medicaid
  767  pharmacy provider.
  768         c. Active, Medicaid-enrolled orthopedic physician groups,
  769  primarily owned by physicians, which provide only orthotic and
  770  prosthetic devices.
  771         Section 8. Subsection (13) of section 409.9122, Florida
  772  Statutes, is repealed.
  773         Section 9. Section 409.913, Florida Statutes, is amended to
  774  read:
  775         409.913 Oversight of the integrity of the Medicaid
  776  program.—The agency shall operate a program to oversee the
  777  activities of Florida Medicaid recipients, and providers and
  778  their representatives, to ensure that fraudulent and abusive
  779  behavior and neglect of recipients occur to the minimum extent
  780  possible, and to recover overpayments and impose sanctions as
  781  appropriate. Beginning January 1, 2003, and each year
  782  thereafter, the agency and the Medicaid Fraud Control Unit of
  783  the Department of Legal Affairs shall submit a joint report to
  784  the Legislature documenting the effectiveness of the state’s
  785  efforts to control Medicaid fraud and abuse and to recover
  786  Medicaid overpayments during the previous fiscal year. The
  787  report must describe the number of cases opened and investigated
  788  each year; the sources of the cases opened; the disposition of
  789  the cases closed each year; the amount of overpayments alleged
  790  in preliminary and final audit letters; the number and amount of
  791  fines or penalties imposed; any reductions in overpayment
  792  amounts negotiated in settlement agreements or by other means;
  793  the amount of final agency determinations of overpayments; the
  794  amount deducted from federal claiming as a result of
  795  overpayments; the amount of overpayments recovered each year;
  796  the amount of cost of investigation recovered each year; the
  797  average length of time to collect from the time the case was
  798  opened until the overpayment is paid in full; the amount
  799  determined as uncollectible and the portion of the uncollectible
  800  amount subsequently reclaimed from the Federal Government; the
  801  number of providers, by type, that are terminated from
  802  participation in the Medicaid program as a result of fraud and
  803  abuse; and all costs associated with discovering and prosecuting
  804  cases of Medicaid overpayments and making recoveries in such
  805  cases. The report must also document actions taken to prevent
  806  overpayments and the number of providers prevented from
  807  enrolling in or reenrolling in the Medicaid program as a result
  808  of documented Medicaid fraud and abuse and must include policy
  809  recommendations necessary to prevent or recover overpayments and
  810  changes necessary to prevent and detect Medicaid fraud. All
  811  policy recommendations in the report must include a detailed
  812  fiscal analysis, including, but not limited to, implementation
  813  costs, estimated savings to the Medicaid program, and the return
  814  on investment. The agency must submit the policy recommendations
  815  and fiscal analyses in the report to the appropriate estimating
  816  conference, pursuant to s. 216.137, by February 15 of each year.
  817  The agency and the Medicaid Fraud Control Unit of the Department
  818  of Legal Affairs each must include detailed unit-specific
  819  performance standards, benchmarks, and metrics in the report,
  820  including projected cost savings to the state Medicaid program
  821  during the following fiscal year.
  822         (1) For the purposes of this section, the term:
  823         (a) “Abuse” means:
  824         1. Provider practices that are inconsistent with generally
  825  accepted business or medical practices and that result in an
  826  unnecessary cost to the Medicaid program or in reimbursement for
  827  goods or services that are not medically necessary or that fail
  828  to meet professionally recognized standards for health care.
  829         2. Recipient practices that result in unnecessary cost to
  830  the Medicaid program.
  831         (b) “Complaint” means an allegation that fraud, abuse, or
  832  an overpayment has occurred.
  833         (c) “Fraud” means an intentional deception or
  834  misrepresentation made by a person with the knowledge that the
  835  deception results in unauthorized benefit to herself or himself
  836  or another person. The term includes any act that constitutes
  837  fraud under applicable federal or state law.
  838         (d) “Medical necessity” or “medically necessary” means any
  839  goods or services necessary to palliate the effects of a
  840  terminal condition, or to prevent, diagnose, correct, cure,
  841  alleviate, or preclude deterioration of a condition that
  842  threatens life, causes pain or suffering, or results in illness
  843  or infirmity, which goods or services are provided in accordance
  844  with generally accepted standards of medical practice. For
  845  purposes of determining Medicaid reimbursement, the agency is
  846  the final arbiter of medical necessity. Determinations of
  847  medical necessity must be made by a licensed physician employed
  848  by or under contract with the agency and must be based upon
  849  information available at the time the goods or services are
  850  provided.
  851         (e) “Overpayment” includes any amount that is not
  852  authorized to be paid by the Medicaid program whether paid as a
  853  result of inaccurate or improper cost reporting, improper
  854  claiming, unacceptable practices, fraud, abuse, or mistake.
  855         (f) “Person” means any natural person, corporation,
  856  partnership, association, clinic, group, or other entity,
  857  whether or not such person is enrolled in the Medicaid program
  858  or is a provider of health care.
  859         (2) The agency shall conduct, or cause to be conducted by
  860  contract or otherwise, reviews, investigations, analyses,
  861  audits, or any combination thereof, to determine possible fraud,
  862  abuse, overpayment, or recipient neglect in the Medicaid program
  863  and shall report the findings of any overpayments in audit
  864  reports as appropriate. At least 5 percent of all audits shall
  865  be conducted on a random basis. As part of its ongoing fraud
  866  detection activities, the agency shall identify and monitor, by
  867  contract or otherwise, patterns of overutilization of Medicaid
  868  services based on state averages. The agency shall track
  869  Medicaid provider prescription and billing patterns and evaluate
  870  them against Medicaid medical necessity criteria and coverage
  871  and limitation guidelines adopted by rule. Medical necessity
  872  determination requires that service be consistent with symptoms
  873  or confirmed diagnosis of illness or injury under treatment and
  874  not in excess of the patient’s needs. The agency shall conduct
  875  reviews of provider exceptions to peer group norms and shall,
  876  using statistical methodologies, provider profiling, and
  877  analysis of billing patterns, detect and investigate abnormal or
  878  unusual increases in billing or payment of claims for Medicaid
  879  services and medically unnecessary provision of services.
  880         (3) The agency may conduct, or may contract for, prepayment
  881  review of provider claims to ensure cost-effective purchasing;
  882  to ensure that billing by a provider to the agency is in
  883  accordance with applicable provisions of all Medicaid rules,
  884  regulations, handbooks, and policies and in accordance with
  885  federal, state, and local law; and to ensure that appropriate
  886  care is rendered to Medicaid recipients. Such prepayment reviews
  887  may be conducted as determined appropriate by the agency,
  888  without any suspicion or allegation of fraud, abuse, or neglect,
  889  and may last for up to 1 year. Unless the agency has reliable
  890  evidence of fraud, misrepresentation, abuse, or neglect, claims
  891  shall be adjudicated for denial or payment within 90 days after
  892  receipt of complete documentation by the agency for review. If
  893  there is reliable evidence of fraud, misrepresentation, abuse,
  894  or neglect, claims shall be adjudicated for denial of payment
  895  within 180 days after receipt of complete documentation by the
  896  agency for review.
  897         (4) Any suspected criminal violation identified by the
  898  agency must be referred to the Medicaid Fraud Control Unit of
  899  the Office of the Attorney General for investigation. The agency
  900  and the Attorney General shall enter into a memorandum of
  901  understanding, which must include, but need not be limited to, a
  902  protocol for regularly sharing information and coordinating
  903  casework. The protocol must establish a procedure for the
  904  referral by the agency of cases involving suspected Medicaid
  905  fraud to the Medicaid Fraud Control Unit for investigation, and
  906  the return to the agency of those cases where investigation
  907  determines that administrative action by the agency is
  908  appropriate. Offices of the Medicaid program integrity program
  909  and the Medicaid Fraud Control Unit of the Department of Legal
  910  Affairs, shall, to the extent possible, be collocated. The
  911  agency and the Department of Legal Affairs shall periodically
  912  conduct joint training and other joint activities designed to
  913  increase communication and coordination in recovering
  914  overpayments.
  915         (5) A Medicaid provider is subject to having goods and
  916  services that are paid for by the Medicaid program reviewed by
  917  an appropriate peer-review organization designated by the
  918  agency. The written findings of the applicable peer-review
  919  organization are admissible in any court or administrative
  920  proceeding as evidence of medical necessity or the lack thereof.
  921         (6) Any notice required to be given to a provider under
  922  this section is presumed to be sufficient notice if sent to the
  923  address last shown on the provider enrollment file. It is the
  924  responsibility of the provider to furnish and keep the agency
  925  informed of the provider’s current address. United States Postal
  926  Service proof of mailing or certified or registered mailing of
  927  such notice to the provider at the address shown on the provider
  928  enrollment file constitutes sufficient proof of notice. Any
  929  notice required to be given to the agency by this section must
  930  be sent to the agency at an address designated by rule.
  931         (7) When presenting a claim for payment under the Medicaid
  932  program, a provider has an affirmative duty to supervise the
  933  provision of, and be responsible for, goods and services claimed
  934  to have been provided, to supervise and be responsible for
  935  preparation and submission of the claim, and to present a claim
  936  that is true and accurate and that is for goods and services
  937  that:
  938         (a) Have actually been furnished to the recipient by the
  939  provider prior to submitting the claim.
  940         (b) Are Medicaid-covered goods or services that are
  941  medically necessary.
  942         (c) Are of a quality comparable to those furnished to the
  943  general public by the provider’s peers.
  944         (d) Have not been billed in whole or in part to a recipient
  945  or a recipient’s responsible party, except for such copayments,
  946  coinsurance, or deductibles as are authorized by the agency.
  947         (e) Are provided in accord with applicable provisions of
  948  all Medicaid rules, regulations, handbooks, and policies and in
  949  accordance with federal, state, and local law.
  950         (f) Are documented by records made at the time the goods or
  951  services were provided, demonstrating the medical necessity for
  952  the goods or services rendered. Medicaid goods or services are
  953  excessive or not medically necessary unless both the medical
  954  basis and the specific need for them are fully and properly
  955  documented in the recipient’s medical record.
  956  
  957  The agency shall deny payment or require repayment for goods or
  958  services that are not presented as required in this subsection.
  959         (8) The agency shall not reimburse any person or entity for
  960  any prescription for medications, medical supplies, or medical
  961  services if the prescription was written by a physician or other
  962  prescribing practitioner who is not enrolled in the Medicaid
  963  program. This section does not apply:
  964         (a) In instances involving bona fide emergency medical
  965  conditions as determined by the agency;
  966         (b) To a provider of medical services to a patient in a
  967  hospital emergency department, hospital inpatient or outpatient
  968  setting, or nursing home;
  969         (c) To bona fide pro bono services by preapproved non
  970  Medicaid providers as determined by the agency;
  971         (d) To prescribing physicians who are board-certified
  972  specialists treating Medicaid recipients referred for treatment
  973  by a treating physician who is enrolled in the Medicaid program;
  974         (e) To prescriptions written for dually eligible Medicare
  975  beneficiaries by an authorized Medicare provider who is not
  976  enrolled in the Medicaid program;
  977         (f) To other physicians who are not enrolled in the
  978  Medicaid program but who provide a medically necessary service
  979  or prescription not otherwise reasonably available from a
  980  Medicaid-enrolled physician; or
  981         (9) A Medicaid provider shall retain medical, professional,
  982  financial, and business records pertaining to services and goods
  983  furnished to a Medicaid recipient and billed to Medicaid for a
  984  period of 6 5 years after the date of furnishing such services
  985  or goods. The agency may investigate, review, or analyze such
  986  records, which must be made available during normal business
  987  hours. However, 24-hour notice must be provided if patient
  988  treatment would be disrupted. The provider is responsible for
  989  furnishing to the agency, and keeping the agency informed of the
  990  location of, the provider’s Medicaid-related records. The
  991  authority of the agency to obtain Medicaid-related records from
  992  a provider is neither curtailed nor limited during a period of
  993  litigation between the agency and the provider.
  994         (10) Payments for the services of billing agents or persons
  995  participating in the preparation of a Medicaid claim shall not
  996  be based on amounts for which they bill nor based on the amount
  997  a provider receives from the Medicaid program.
  998         (11) The agency shall deny payment or require repayment for
  999  inappropriate, medically unnecessary, or excessive goods or
 1000  services from the person furnishing them, the person under whose
 1001  supervision they were furnished, or the person causing them to
 1002  be furnished.
 1003         (12) The complaint and all information obtained pursuant to
 1004  an investigation of a Medicaid provider, or the authorized
 1005  representative or agent of a provider, relating to an allegation
 1006  of fraud, abuse, or neglect are confidential and exempt from the
 1007  provisions of s. 119.07(1):
 1008         (a) Until the agency takes final agency action with respect
 1009  to the provider and requires repayment of any overpayment, or
 1010  imposes an administrative sanction;
 1011         (b) Until the Attorney General refers the case for criminal
 1012  prosecution;
 1013         (c) Until 10 days after the complaint is determined without
 1014  merit; or
 1015         (d) At all times if the complaint or information is
 1016  otherwise protected by law.
 1017         (13) The agency shall immediately terminate participation
 1018  of a Medicaid provider in the Medicaid program and may seek
 1019  civil remedies or impose other administrative sanctions against
 1020  a Medicaid provider, if the provider or any principal, officer,
 1021  director, agent, managing employee, or affiliated person of the
 1022  provider, or any partner or shareholder having an ownership
 1023  interest in the provider equal to 5 percent or greater, has
 1024  been:
 1025         (a) Convicted of a criminal offense related to the delivery
 1026  of any health care goods or services, including the performance
 1027  of management or administrative functions relating to the
 1028  delivery of health care goods or services;
 1029         (b) Convicted of a criminal offense under federal law or
 1030  the law of any state relating to the practice of the provider’s
 1031  profession; or
 1032         (c) Found by a court of competent jurisdiction to have
 1033  neglected or physically abused a patient in connection with the
 1034  delivery of health care goods or services.
 1035  
 1036  If the agency determines a provider did not participate or
 1037  acquiesce in an offense specified in paragraph (a), paragraph
 1038  (b), or paragraph (c), termination will not be imposed. If the
 1039  agency effects a termination under this subsection, the agency
 1040  shall issue an immediate termination final order as provided in
 1041  subsection (16) pursuant to s. 120.569(2)(n).
 1042         (14) If the provider has been suspended or terminated from
 1043  participation in the Medicaid program or the Medicare program by
 1044  the Federal Government or any state, the agency must immediately
 1045  suspend or terminate, as appropriate, the provider’s
 1046  participation in this state’s Medicaid program for a period no
 1047  less than that imposed by the Federal Government or any other
 1048  state, and may not enroll such provider in this state’s Medicaid
 1049  program while such foreign suspension or termination remains in
 1050  effect. The agency shall also immediately suspend or terminate,
 1051  as appropriate, a provider’s participation in this state’s
 1052  Medicaid program if the provider participated or acquiesced in
 1053  any action for which any principal, officer, director, agent,
 1054  managing employee, or affiliated person of the provider, or any
 1055  partner or shareholder having an ownership interest in the
 1056  provider equal to 5 percent or greater, was suspended or
 1057  terminated from participating in the Medicaid program or the
 1058  Medicare program by the Federal Government or any state. This
 1059  sanction is in addition to all other remedies provided by law.
 1060  If the agency suspends or terminates a provider’s participation
 1061  in the state’s Medicaid program under this subsection, the
 1062  agency shall issue an immediate suspension or immediate
 1063  termination order as provided in subsection (16).
 1064         (15) The agency shall seek a remedy provided by law,
 1065  including, but not limited to, any remedy provided in
 1066  subsections (13) and (16) and s. 812.035, if:
 1067         (a) The provider’s license has not been renewed, or has
 1068  been revoked, suspended, or terminated, for cause, by the
 1069  licensing agency of any state;
 1070         (b) The provider has failed to make available or has
 1071  refused access to Medicaid-related records to an auditor,
 1072  investigator, or other authorized employee or agent of the
 1073  agency, the Attorney General, a state attorney, or the Federal
 1074  Government;
 1075         (c) The provider has not furnished or has failed to make
 1076  available such Medicaid-related records as the agency has found
 1077  necessary to determine whether Medicaid payments are or were due
 1078  and the amounts thereof;
 1079         (d) The provider has failed to maintain medical records
 1080  made at the time of service, or prior to service if prior
 1081  authorization is required, demonstrating the necessity and
 1082  appropriateness of the goods or services rendered;
 1083         (e) The provider is not in compliance with provisions of
 1084  Medicaid provider publications that have been adopted by
 1085  reference as rules in the Florida Administrative Code; with
 1086  provisions of state or federal laws, rules, or regulations; with
 1087  provisions of the provider agreement between the agency and the
 1088  provider; or with certifications found on claim forms or on
 1089  transmittal forms for electronically submitted claims that are
 1090  submitted by the provider or authorized representative, as such
 1091  provisions apply to the Medicaid program;
 1092         (f) The provider or person who ordered or prescribed the
 1093  care, services, or supplies has furnished, or ordered the
 1094  furnishing of, goods or services to a recipient which are
 1095  inappropriate, unnecessary, excessive, or harmful to the
 1096  recipient or are of inferior quality;
 1097         (g) The provider has demonstrated a pattern of failure to
 1098  provide goods or services that are medically necessary;
 1099         (h) The provider or an authorized representative of the
 1100  provider, or a person who ordered or prescribed the goods or
 1101  services, has submitted or caused to be submitted false or a
 1102  pattern of erroneous Medicaid claims;
 1103         (i) The provider or an authorized representative of the
 1104  provider, or a person who has ordered or prescribed the goods or
 1105  services, has submitted or caused to be submitted a Medicaid
 1106  provider enrollment application, a request for prior
 1107  authorization for Medicaid services, a drug exception request,
 1108  or a Medicaid cost report that contains materially false or
 1109  incorrect information;
 1110         (j) The provider or an authorized representative of the
 1111  provider has collected from or billed a recipient or a
 1112  recipient’s responsible party improperly for amounts that should
 1113  not have been so collected or billed by reason of the provider’s
 1114  billing the Medicaid program for the same service;
 1115         (k) The provider or an authorized representative of the
 1116  provider has included in a cost report costs that are not
 1117  allowable under a Florida Title XIX reimbursement plan, after
 1118  the provider or authorized representative had been advised in an
 1119  audit exit conference or audit report that the costs were not
 1120  allowable;
 1121         (l) The provider is charged by information or indictment
 1122  with fraudulent billing practices or an offense under subsection
 1123  (13). The sanction applied for this reason is limited to
 1124  suspension of the provider’s participation in the Medicaid
 1125  program for the duration of the indictment unless the provider
 1126  is found guilty pursuant to the information or indictment;
 1127         (m) The provider or a person who has ordered or prescribed
 1128  the goods or services is found liable for negligent practice
 1129  resulting in death or injury to the provider’s patient;
 1130         (n) The provider fails to demonstrate that it had available
 1131  during a specific audit or review period sufficient quantities
 1132  of goods, or sufficient time in the case of services, to support
 1133  the provider’s billings to the Medicaid program;
 1134         (o) The provider has failed to comply with the notice and
 1135  reporting requirements of s. 409.907;
 1136         (p) The agency has received reliable information of patient
 1137  abuse or neglect or of any act prohibited by s. 409.920; or
 1138         (q) The provider has failed to comply with an agreed-upon
 1139  repayment schedule.
 1140  
 1141  A provider is subject to sanctions for violations of this
 1142  subsection as the result of actions or inactions of the
 1143  provider, or actions or inactions of any principal, officer,
 1144  director, agent, managing employee, or affiliated person of the
 1145  provider, or any partner or shareholder having an ownership
 1146  interest in the provider equal to 5 percent or greater, in which
 1147  the provider participated or acquiesced. If the agency
 1148  immediately suspends or immediately terminates a provider under
 1149  this subsection, the agency shall issue an immediate suspension
 1150  or immediate termination order as provided in subsection (16).
 1151         (16) The agency shall impose any of the following sanctions
 1152  or disincentives on a provider or a person for any of the acts
 1153  described in subsection (15):
 1154         (a) Suspension for a specific period of time of not more
 1155  than 1 year. Suspension shall preclude participation in the
 1156  Medicaid program, which includes any action that results in a
 1157  claim for payment to the Medicaid program as a result of
 1158  furnishing, supervising a person who is furnishing, or causing a
 1159  person to furnish goods or services.
 1160         (b) Termination for a specific period of time of from more
 1161  than 1 year to 20 years. Termination shall preclude
 1162  participation in the Medicaid program, which includes any action
 1163  that results in a claim for payment to the Medicaid program as a
 1164  result of furnishing, supervising a person who is furnishing, or
 1165  causing a person to furnish goods or services.
 1166         (c) Imposition of a fine of up to $5,000 for each
 1167  violation. Each day that an ongoing violation continues, such as
 1168  refusing to furnish Medicaid-related records or refusing access
 1169  to records, is considered, for the purposes of this section, to
 1170  be a separate violation. Each instance of improper billing of a
 1171  Medicaid recipient; each instance of including an unallowable
 1172  cost on a hospital or nursing home Medicaid cost report after
 1173  the provider or authorized representative has been advised in an
 1174  audit exit conference or previous audit report of the cost
 1175  unallowability; each instance of furnishing a Medicaid recipient
 1176  goods or professional services that are inappropriate or of
 1177  inferior quality as determined by competent peer judgment; each
 1178  instance of knowingly submitting a materially false or erroneous
 1179  Medicaid provider enrollment application, request for prior
 1180  authorization for Medicaid services, drug exception request, or
 1181  cost report; each instance of inappropriate prescribing of drugs
 1182  for a Medicaid recipient as determined by competent peer
 1183  judgment; and each false or erroneous Medicaid claim leading to
 1184  an overpayment to a provider is considered, for the purposes of
 1185  this section, to be a separate violation.
 1186         (d) Immediate suspension, if the agency has received
 1187  information of patient abuse or neglect, or of any act
 1188  prohibited by s. 409.920, or any conduct listed in subsection
 1189  (13) or subsection (14). Upon suspension, the agency must issue
 1190  an immediate suspension final order, which shall state that the
 1191  agency has reasonable cause to believe that the provider,
 1192  person, or entity named is engaging in or has engaged in patient
 1193  abuse or neglect, any act prohibited by s. 409.920, or any
 1194  conduct listed in subsection (13) or subsection (14). The order
 1195  shall provide notice of administrative hearing rights under ss.
 1196  120.569 and 120.57 and is effective immediately upon notice to
 1197  the provider, person, or entity under s. 120.569(2)(n).
 1198         (e)Immediate termination, if the agency has received
 1199  information of a conviction based on patient abuse or neglect,
 1200  any act prohibited by s. 409.920, or any conduct listed in
 1201  subsection (13) or subsection (14). Upon termination, the agency
 1202  must issue an immediate termination order, which shall state
 1203  that the agency has reasonable cause to believe that the
 1204  provider, person, or entity named has been convicted of patient
 1205  abuse or neglect, any act prohibited by s. 409.920, or any
 1206  conduct listed in subsection (13) or subsection (14). The
 1207  termination order shall provide notice of administrative hearing
 1208  rights under ss. 120.569 and 120.57 and is effective immediately
 1209  upon notice to the provider, person, or entity.
 1210         (f)(e) A fine, not to exceed $10,000, for a violation of
 1211  paragraph (15)(i).
 1212         (g)(f) Imposition of liens against provider assets,
 1213  including, but not limited to, financial assets and real
 1214  property, not to exceed the amount of fines or recoveries
 1215  sought, upon entry of an order determining that such moneys are
 1216  due or recoverable.
 1217         (h)(g) Prepayment reviews of claims for a specified period
 1218  of time.
 1219         (i)(h) Comprehensive followup reviews of providers every 6
 1220  months to ensure that they are billing Medicaid correctly.
 1221         (j)(i) Corrective-action plans that would remain in effect
 1222  for providers for up to 3 years and that would be monitored by
 1223  the agency every 6 months while in effect.
 1224         (k)(j) Other remedies as permitted by law to effect the
 1225  recovery of a fine or overpayment.
 1226  
 1227  The Secretary of Health Care Administration may make a
 1228  determination that imposition of a sanction or disincentive is
 1229  not in the best interest of the Medicaid program, in which case
 1230  a sanction or disincentive shall not be imposed.
 1231         (17) In determining the appropriate administrative sanction
 1232  to be applied, or the duration of any suspension or termination,
 1233  the agency shall consider:
 1234         (a) The seriousness and extent of the violation or
 1235  violations.
 1236         (b) Any prior history of violations by the provider
 1237  relating to the delivery of health care programs which resulted
 1238  in either a criminal conviction or in administrative sanction or
 1239  penalty.
 1240         (c) Evidence of continued violation within the provider’s
 1241  management control of Medicaid statutes, rules, regulations, or
 1242  policies after written notification to the provider of improper
 1243  practice or instance of violation.
 1244         (d) The effect, if any, on the quality of medical care
 1245  provided to Medicaid recipients as a result of the acts of the
 1246  provider.
 1247         (e) Any action by a licensing agency respecting the
 1248  provider in any state in which the provider operates or has
 1249  operated.
 1250         (f) The apparent impact on access by recipients to Medicaid
 1251  services if the provider is suspended or terminated, in the best
 1252  judgment of the agency.
 1253  
 1254  The agency shall document the basis for all sanctioning actions
 1255  and recommendations.
 1256         (18) The agency may take action to sanction, suspend, or
 1257  terminate a particular provider working for a group provider,
 1258  and may suspend or terminate Medicaid participation at a
 1259  specific location, rather than or in addition to taking action
 1260  against an entire group.
 1261         (19) The agency shall establish a process for conducting
 1262  followup reviews of a sampling of providers who have a history
 1263  of overpayment under the Medicaid program. This process must
 1264  consider the magnitude of previous fraud or abuse and the
 1265  potential effect of continued fraud or abuse on Medicaid costs.
 1266         (20) In making a determination of overpayment to a
 1267  provider, the agency must use accepted and valid auditing,
 1268  accounting, analytical, statistical, or peer-review methods, or
 1269  combinations thereof. Appropriate statistical methods may
 1270  include, but are not limited to, sampling and extension to the
 1271  population, parametric and nonparametric statistics, tests of
 1272  hypotheses, and other generally accepted statistical methods.
 1273  Appropriate analytical methods may include, but are not limited
 1274  to, reviews to determine variances between the quantities of
 1275  products that a provider had on hand and available to be
 1276  purveyed to Medicaid recipients during the review period and the
 1277  quantities of the same products paid for by the Medicaid program
 1278  for the same period, taking into appropriate consideration sales
 1279  of the same products to non-Medicaid customers during the same
 1280  period. In meeting its burden of proof in any administrative or
 1281  court proceeding, the agency may introduce the results of such
 1282  statistical methods as evidence of overpayment.
 1283         (21) When making a determination that an overpayment has
 1284  occurred, the agency shall prepare and issue an audit report to
 1285  the provider showing the calculation of overpayments.
 1286         (22) The audit report, supported by agency work papers,
 1287  showing an overpayment to a provider constitutes evidence of the
 1288  overpayment. A provider may not present or elicit testimony,
 1289  either on direct examination or cross-examination in any court
 1290  or administrative proceeding, regarding the purchase or
 1291  acquisition by any means of drugs, goods, or supplies; sales or
 1292  divestment by any means of drugs, goods, or supplies; or
 1293  inventory of drugs, goods, or supplies, unless such acquisition,
 1294  sales, divestment, or inventory is documented by written
 1295  invoices, written inventory records, or other competent written
 1296  documentary evidence maintained in the normal course of the
 1297  provider’s business. Notwithstanding the applicable rules of
 1298  discovery, all documentation that will be offered as evidence at
 1299  an administrative hearing on a Medicaid overpayment must be
 1300  exchanged by all parties at least 14 days before the
 1301  administrative hearing or must be excluded from consideration.
 1302         (23)(a) In an audit or investigation of a violation
 1303  committed by a provider which is conducted pursuant to this
 1304  section, the agency is entitled to recover all investigative,
 1305  legal, and expert witness costs if the agency’s findings were
 1306  not contested by the provider or, if contested, the agency
 1307  ultimately prevailed.
 1308         (b) The agency has the burden of documenting the costs,
 1309  which include salaries and employee benefits and out-of-pocket
 1310  expenses. The amount of costs that may be recovered must be
 1311  reasonable in relation to the seriousness of the violation and
 1312  must be set taking into consideration the financial resources,
 1313  earning ability, and needs of the provider, who has the burden
 1314  of demonstrating such factors.
 1315         (c) The provider may pay the costs over a period to be
 1316  determined by the agency if the agency determines that an
 1317  extreme hardship would result to the provider from immediate
 1318  full payment. Any default in payment of costs may be collected
 1319  by any means authorized by law.
 1320         (24) If the agency imposes an administrative sanction
 1321  pursuant to subsection (13), subsection (14), or subsection
 1322  (15), except paragraphs (15)(e) and (o), upon any provider or
 1323  any principal, officer, director, agent, managing employee, or
 1324  affiliated person of the provider who is regulated by another
 1325  state entity, the agency shall notify that other entity of the
 1326  imposition of the sanction within 5 business days. Such
 1327  notification must include the provider’s or person’s name and
 1328  license number and the specific reasons for sanction.
 1329         (25)(a) The agency shall withhold Medicaid payments, in
 1330  whole or in part, to a provider upon receipt of reliable
 1331  evidence that the circumstances giving rise to the need for a
 1332  withholding of payments involve fraud, willful
 1333  misrepresentation, or abuse under the Medicaid program, or a
 1334  crime committed while rendering goods or services to Medicaid
 1335  recipients. If the provider is not paid within 14 days after the
 1336  agency receives evidence it is determined that fraud, willful
 1337  misrepresentation, abuse, or a crime did not occur, interest
 1338  shall accrue at a rate of 10 percent a year the payments
 1339  withheld must be paid to the provider within 14 days after such
 1340  determination with interest at the rate of 10 percent a year.
 1341  Any money withheld in accordance with this paragraph shall be
 1342  placed in a suspended account, readily accessible to the agency,
 1343  so that any payment ultimately due the provider shall be made
 1344  within 14 days.
 1345         (b) The agency shall deny payment, or require repayment, if
 1346  the goods or services were furnished, supervised, or caused to
 1347  be furnished by a person who has been convicted of a crime under
 1348  subsection (13) or who has been suspended or terminated from the
 1349  Medicaid program or Medicare program by the Federal Government
 1350  or any state.
 1351         (c) Overpayments owed to the agency bear interest at the
 1352  rate of 10 percent per year from the date of determination of
 1353  the overpayment by the agency, and payment arrangements for
 1354  overpayments and fines must be made within 35 days after the
 1355  date of the final order at the conclusion of legal proceedings.
 1356  A provider who does not enter into or adhere to an agreed-upon
 1357  repayment schedule may be terminated by the agency for
 1358  nonpayment or partial payment.
 1359         (d) The agency, upon entry of a final agency order, a
 1360  judgment or order of a court of competent jurisdiction, or a
 1361  stipulation or settlement, may collect the moneys owed by all
 1362  means allowable by law, including, but not limited to, notifying
 1363  any fiscal intermediary of Medicare benefits that the state has
 1364  a superior right of payment. Upon receipt of such written
 1365  notification, the Medicare fiscal intermediary shall remit to
 1366  the state the sum claimed.
 1367         (e) The agency may institute amnesty programs to allow
 1368  Medicaid providers the opportunity to voluntarily repay
 1369  overpayments. The agency may adopt rules to administer such
 1370  programs.
 1371         (26) The agency may impose administrative sanctions against
 1372  a Medicaid recipient, or the agency may seek any other remedy
 1373  provided by law, including, but not limited to, the remedies
 1374  provided in s. 812.035, if the agency finds that a recipient has
 1375  engaged in solicitation in violation of s. 409.920 or that the
 1376  recipient has otherwise abused the Medicaid program.
 1377         (27) When the Agency for Health Care Administration has
 1378  made a probable cause determination and alleged that an
 1379  overpayment to a Medicaid provider has occurred, the agency,
 1380  after notice to the provider, shall:
 1381         (a) Withhold, and continue to withhold during the pendency
 1382  of an administrative hearing pursuant to chapter 120, any
 1383  medical assistance reimbursement payments until such time as the
 1384  overpayment is recovered, unless within 30 days after receiving
 1385  notice thereof the provider:
 1386         1. Makes repayment in full; or
 1387         2. Establishes a repayment plan that is satisfactory to the
 1388  Agency for Health Care Administration.
 1389         (b) Withhold, and continue to withhold during the pendency
 1390  of an administrative hearing pursuant to chapter 120, medical
 1391  assistance reimbursement payments if the terms of a repayment
 1392  plan are not adhered to by the provider.
 1393         (28) Venue for all Medicaid program integrity overpayment
 1394  cases shall lie in Leon County, at the discretion of the agency.
 1395         (29) Notwithstanding other provisions of law, the agency
 1396  and the Medicaid Fraud Control Unit of the Department of Legal
 1397  Affairs may review a provider’s Medicaid-related and non
 1398  Medicaid-related records in order to determine the total output
 1399  of a provider’s practice to reconcile quantities of goods or
 1400  services billed to Medicaid with quantities of goods or services
 1401  used in the provider’s total practice.
 1402         (30) The agency shall terminate a provider’s participation
 1403  in the Medicaid program if the provider fails to reimburse an
 1404  overpayment or fine that has been determined by final order, not
 1405  subject to further appeal, within 35 days after the date of the
 1406  final order, unless the provider and the agency have entered
 1407  into a repayment agreement.
 1408         (31) If a provider requests an administrative hearing
 1409  pursuant to chapter 120, such hearing must be conducted within
 1410  90 days following assignment of an administrative law judge,
 1411  absent exceptionally good cause shown as determined by the
 1412  administrative law judge or hearing officer. Upon issuance of a
 1413  final order, the outstanding balance of the amount determined to
 1414  constitute the overpayment or fine shall become due. If a
 1415  provider fails to make payments in full, fails to enter into a
 1416  satisfactory repayment plan, or fails to comply with the terms
 1417  of a repayment plan or settlement agreement, the agency shall
 1418  withhold medical assistance reimbursement payments until the
 1419  amount due is paid in full.
 1420         (32) Duly authorized agents and employees of the agency
 1421  shall have the power to inspect, during normal business hours,
 1422  the records of any pharmacy, wholesale establishment, or
 1423  manufacturer, or any other place in which drugs and medical
 1424  supplies are manufactured, packed, packaged, made, stored, sold,
 1425  or kept for sale, for the purpose of verifying the amount of
 1426  drugs and medical supplies ordered, delivered, or purchased by a
 1427  provider. The agency shall provide at least 2 business days’
 1428  prior notice of any such inspection. The notice must identify
 1429  the provider whose records will be inspected, and the inspection
 1430  shall include only records specifically related to that
 1431  provider.
 1432         (33) In accordance with federal law, Medicaid recipients
 1433  convicted of a crime pursuant to 42 U.S.C. s. 1320a-7b may be
 1434  limited, restricted, or suspended from Medicaid eligibility for
 1435  a period not to exceed 1 year, as determined by the agency head
 1436  or designee.
 1437         (34) To deter fraud and abuse in the Medicaid program, the
 1438  agency may limit the number of Schedule II and Schedule III
 1439  refill prescription claims submitted from a pharmacy provider.
 1440  The agency shall limit the allowable amount of reimbursement of
 1441  prescription refill claims for Schedule II and Schedule III
 1442  pharmaceuticals if the agency or the Medicaid Fraud Control Unit
 1443  determines that the specific prescription refill was not
 1444  requested by the Medicaid recipient or authorized representative
 1445  for whom the refill claim is submitted or was not prescribed by
 1446  the recipient’s medical provider or physician. Any such refill
 1447  request must be consistent with the original prescription.
 1448         (35) The Office of Program Policy Analysis and Government
 1449  Accountability shall provide a report to the President of the
 1450  Senate and the Speaker of the House of Representatives on a
 1451  biennial basis, beginning January 31, 2006, on the agency’s and
 1452  the Medicaid Fraud Control Unit’s efforts to prevent, detect,
 1453  and deter, as well as recover funds lost to, fraud and abuse in
 1454  the Medicaid program.
 1455         (36) At least three times a year, the agency shall provide
 1456  to each Medicaid recipient or his or her representative an
 1457  explanation of benefits in the form of a letter that is mailed
 1458  to the most recent address of the recipient on the record with
 1459  the Department of Children and Family Services. The explanation
 1460  of benefits must include the patient’s name, the name of the
 1461  health care provider and the address of the location where the
 1462  service was provided, a description of all services billed to
 1463  Medicaid in terminology that should be understood by a
 1464  reasonable person, and information on how to report
 1465  inappropriate or incorrect billing to the agency or other law
 1466  enforcement entities for review or investigation. At least once
 1467  a year, the letter also must include information on how to
 1468  report criminal Medicaid fraud, the Medicaid Fraud Control
 1469  Unit’s toll-free hotline number, and information about the
 1470  rewards available under s. 409.9203. The explanation of benefits
 1471  may not be mailed for Medicaid independent laboratory services
 1472  as described in s. 409.905(7) or for Medicaid certified match
 1473  services as described in ss. 409.9071 and 1011.70.
 1474         (37) The agency shall post on its website a current list of
 1475  each Medicaid provider, including any principal, officer,
 1476  director, agent, managing employee, or affiliated person of the
 1477  provider, or any partner or shareholder having an ownership
 1478  interest in the provider equal to 5 percent or greater, who has
 1479  been terminated for cause from the Medicaid program or
 1480  sanctioned under this section. The list must be searchable by a
 1481  variety of search parameters and provide for the creation of
 1482  formatted lists that may be printed or imported into other
 1483  applications, including spreadsheets. The agency shall update
 1484  the list at least monthly.
 1485         (38) In order to improve the detection of health care
 1486  fraud, use technology to prevent and detect fraud, and maximize
 1487  the electronic exchange of health care fraud information, the
 1488  agency shall:
 1489         (a) Compile, maintain, and publish on its website a
 1490  detailed list of all state and federal databases that contain
 1491  health care fraud information and update the list at least
 1492  biannually;
 1493         (b) Develop a strategic plan to connect all databases that
 1494  contain health care fraud information to facilitate the
 1495  electronic exchange of health information between the agency,
 1496  the Department of Health, the Department of Law Enforcement, and
 1497  the Attorney General’s Office. The plan must include recommended
 1498  standard data formats, fraud identification strategies, and
 1499  specifications for the technical interface between state and
 1500  federal health care fraud databases;
 1501         (c) Monitor innovations in health information technology,
 1502  specifically as it pertains to Medicaid fraud prevention and
 1503  detection; and
 1504         (d) Periodically publish policy briefs that highlight
 1505  available new technology to prevent or detect health care fraud
 1506  and projects implemented by other states, the private sector, or
 1507  the Federal Government which use technology to prevent or detect
 1508  health care fraud.
 1509         Section 10. Subsection (5) is added to section 409.9203,
 1510  Florida Statutes, to read:
 1511         409.9203 Rewards for reporting Medicaid fraud.—
 1512         (5)An employee of the Agency for Health Care
 1513  Administration, the Department of Legal Affairs, the Department
 1514  of Health, or the Department of Law Enforcement whose job
 1515  responsibilities include the prevention, detection, and
 1516  prosecution of Medicaid fraud is not eligible to receive a
 1517  reward under this section.
 1518         Section 11. Subsection (8) is added to section 456.001,
 1519  Florida Statutes, to read:
 1520         456.001 Definitions.—As used in this chapter, the term:
 1521         (8)“Affiliate” or “affiliated person” means any person who
 1522  directly or indirectly manages, controls, or oversees the
 1523  operation of a corporation or other business entity, regardless
 1524  of whether such person is a partner, shareholder, owner,
 1525  officer, director, or agent of the entity.
 1526         Section 12. Paragraph (c) of subsection (1) and subsections
 1527  (2) and (3) of section 456.041, Florida Statutes, are amended to
 1528  read:
 1529         456.041 Practitioner profile; creation.—
 1530         (1)
 1531         (c) Within 30 calendar days after receiving an update of
 1532  information required for the practitioner’s profile, the
 1533  department shall update the practitioner’s profile in accordance
 1534  with the requirements of subsection (8) (7).
 1535         (2) Beginning July 1, 2010, on the profile published under
 1536  subsection (1), the department shall include indicate if the
 1537  information provided under s. 456.039(1)(a)7. or s.
 1538  456.0391(1)(a)7. and indicate if the information is or is not
 1539  corroborated by a criminal history records check conducted
 1540  according to this subsection. The department must include in
 1541  each practitioner’s profile the following statement: “The
 1542  criminal history information, if any exists, may be incomplete.
 1543  Federal criminal history information is not available to the
 1544  public.” The department, or the board having regulatory
 1545  authority over the practitioner acting on behalf of the
 1546  department, shall investigate any information received by the
 1547  department or the board.
 1548         (3) Beginning July 1, 2010, the department shall include in
 1549  each practitioner’s profile any open administrative complaint
 1550  filed with the department against the practitioner in which
 1551  probable cause has been found. The Department of Health shall
 1552  include in each practitioner’s practitioner profile that
 1553  criminal information that directly relates to the practitioner’s
 1554  ability to competently practice his or her profession. The
 1555  department must include in each practitioner’s practitioner
 1556  profile the following statement: “The criminal history
 1557  information, if any exists, may be incomplete; federal criminal
 1558  history information is not available to the public.” The
 1559  department shall provide in each practitioner profile, for every
 1560  final disciplinary action taken against the practitioner, an
 1561  easy-to-read narrative description that explains the
 1562  administrative complaint filed against the practitioner and the
 1563  final disciplinary action imposed on the practitioner. The
 1564  department shall include a hyperlink to each final order listed
 1565  in its website report of dispositions of recent disciplinary
 1566  actions taken against practitioners.
 1567         Section 13. Section 456.0635, Florida Statutes, is amended
 1568  to read:
 1569         456.0635 Health care Medicaid fraud; disqualification for
 1570  license, certificate, or registration.—
 1571         (1) Medicaid Fraud in the practice of a health care
 1572  profession is prohibited.
 1573         (2) Each board within the jurisdiction of the department,
 1574  or the department if there is no board, shall refuse to admit a
 1575  candidate to any examination and refuse to issue or renew a
 1576  license, certificate, or registration to any applicant if the
 1577  candidate or applicant or any principal, officer, agent,
 1578  managing employee, or affiliated person of the applicant, has
 1579  been:
 1580         (a) Has been convicted of, or entered a plea of guilty or
 1581  nolo contendere to, regardless of adjudication, a felony under
 1582  chapter 409, chapter 817, chapter 893, or a similar felony
 1583  offense committed in another state or jurisdiction 21 U.S.C. ss.
 1584  801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and any
 1585  subsequent period of probation for such conviction or plea pleas
 1586  ended: more than 15 years prior to the date of the application;
 1587         1.For felonies of the first or second degree more than 15
 1588  years before the date of application.
 1589         2.For felonies of the third degree more than 10 years
 1590  before the date of application, except for felonies of the third
 1591  degree under s. 893.13(6)(a).
 1592         3.For felonies of the third degree under s. 893.13(6)(a),
 1593  more than 5 years before the date of application.
 1594         4.For felonies in which the defendant entered a plea of
 1595  guilty or nolo contendere in an agreement with the court to
 1596  enter a pretrial intervention or drug diversion program, the
 1597  department shall not approve or deny the application for a
 1598  license, certificate, or registration until the final resolution
 1599  of the case.
 1600         (b)Has been convicted of, or entered a plea of guilty or
 1601  nolo contendere to, regardless of adjudication, a felony under
 1602  21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the
 1603  sentence and any subsequent period of probation for such
 1604  conviction or plea ended more than 15 years before the date of
 1605  the application;
 1606         (c)(b)Has been terminated for cause from the Florida
 1607  Medicaid program pursuant to s. 409.913, unless the applicant
 1608  has been in good standing with the Florida Medicaid program for
 1609  the most recent 5 years;
 1610         (d)(c)Has been terminated for cause, pursuant to the
 1611  appeals procedures established by the state or Federal
 1612  Government, from any other state Medicaid program or the federal
 1613  Medicare program, unless the applicant has been in good standing
 1614  with a state Medicaid program or the federal Medicare program
 1615  for the most recent 5 years and the termination occurred at
 1616  least 20 years before prior to the date of the application; or.
 1617         (e)Is currently listed on the United States Department of
 1618  Health and Human Services Office of Inspector General’s List of
 1619  Excluded Individuals and Entities.
 1620         (f) This subsection does not apply to applicants for
 1621  initial licensure or certification who were enrolled in an
 1622  educational or training program on or before July 1, 2009, which
 1623  was recognized by a board or, if there is no board, recognized
 1624  by the department, and who applied for licensure after July 1,
 1625  2009.
 1626         (3)Each board within the jurisdiction of the department,
 1627  or the department if there is no board, shall refuse to renew a
 1628  license, certificate, or registration of any applicant if the
 1629  candidate or applicant or any principal, officer, agent,
 1630  managing employee, or affiliated person of the applicant:
 1631         (a)Has been convicted of, or entered a plea of guilty or
 1632  nolo contendere to, regardless of adjudication, a felony under:
 1633  chapter 409, chapter 817, chapter 893, or a similar felony
 1634  offense committed in another state or jurisdiction since July 1,
 1635  2009.
 1636         (b)Has been convicted of, or entered a plea of guilty or
 1637  nolo contendere to, regardless of adjudication, a felony under
 1638  21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396 since July 1,
 1639  2009.
 1640         (c)Has been terminated for cause from the Florida Medicaid
 1641  program pursuant to s. 409.913, unless the applicant has been in
 1642  good standing with the Florida Medicaid program for the most
 1643  recent 5 years.
 1644         (d)Has been terminated for cause, pursuant to the appeals
 1645  procedures established by the state, from any other state
 1646  Medicaid program, unless the applicant has been in good standing
 1647  with a state Medicaid program for the most recent 5 years and
 1648  the termination occurred at least 20 years before the date of
 1649  the application.
 1650         (e)Is currently listed on the United States Department of
 1651  Health and Human Services Office of Inspector General’s List of
 1652  Excluded Individuals and Entities.
 1653         (f)For felonies in which the defendant entered a plea of
 1654  guilty or nolo contendere in an agreement with the court to
 1655  enter a pretrial intervention or drug diversion program, the
 1656  department shall not approve or deny the application for a
 1657  renewal of a license, certificate, or registration until the
 1658  final resolution of the case.
 1659         (4)(3) Licensed health care practitioners shall report
 1660  allegations of Medicaid fraud to the department, regardless of
 1661  the practice setting in which the alleged Medicaid fraud
 1662  occurred.
 1663         (5)(4) The acceptance by a licensing authority of a
 1664  candidate’s relinquishment of a license which is offered in
 1665  response to or anticipation of the filing of administrative
 1666  charges alleging Medicaid fraud or similar charges constitutes
 1667  the permanent revocation of the license.
 1668         (6)The department shall adopt rules to administer the
 1669  provisions of this section related to denial of licensure
 1670  renewal.
 1671         Section 14. Paragraph (kk) of subsection (1) of section
 1672  456.072, Florida Statutes, is amended to read:
 1673         456.072 Grounds for discipline; penalties; enforcement.—
 1674         (1) The following acts shall constitute grounds for which
 1675  the disciplinary actions specified in subsection (2) may be
 1676  taken:
 1677         (kk) Being terminated from the state Medicaid program
 1678  pursuant to s. 409.913 or, any other state Medicaid program, or
 1679  excluded from the federal Medicare program, unless eligibility
 1680  to participate in the program from which the practitioner was
 1681  terminated has been restored.
 1682         Section 15. Subsection (13) of section 456.073, Florida
 1683  Statutes, is amended to read:
 1684         456.073 Disciplinary proceedings.—Disciplinary proceedings
 1685  for each board shall be within the jurisdiction of the
 1686  department.
 1687         (13) Notwithstanding any provision of law to the contrary,
 1688  an administrative complaint against a licensee shall be filed
 1689  within 6 years after the time of the incident or occurrence
 1690  giving rise to the complaint against the licensee. If such
 1691  incident or occurrence involved fraud related to the Medicaid
 1692  program, criminal actions, diversion of controlled substances,
 1693  sexual misconduct, or impairment by the licensee, this
 1694  subsection does not apply to bar initiation of an investigation
 1695  or filing of an administrative complaint beyond the 6-year
 1696  timeframe. In those cases covered by this subsection in which it
 1697  can be shown that fraud, concealment, or intentional
 1698  misrepresentation of fact prevented the discovery of the
 1699  violation of law, the period of limitations is extended forward,
 1700  but in no event to exceed 12 years after the time of the
 1701  incident or occurrence.
 1702         Section 16. Subsection (1) of section 456.074, Florida
 1703  Statutes, is amended to read:
 1704         456.074 Certain health care practitioners; immediate
 1705  suspension of license.—
 1706         (1) The department shall issue an emergency order
 1707  suspending the license of any person licensed in a profession as
 1708  defined in this chapter under chapter 458, chapter 459, chapter
 1709  460, chapter 461, chapter 462, chapter 463, chapter 464, chapter
 1710  465, chapter 466, or chapter 484 who pleads guilty to, is
 1711  convicted or found guilty of, or who enters a plea of nolo
 1712  contendere to, regardless of adjudication, to:
 1713         (a) A felony under chapter 409, chapter 812, chapter 817,
 1714  or chapter 893, chapter 895, chapter 896, or under 21 U.S.C. ss.
 1715  801-970, or under 42 U.S.C. ss. 1395-1396; or
 1716         (b) A misdemeanor or felony under 18 U.S.C. s. 669, ss.
 1717  285-287, s. 371, s. 1001, s. 1035, s. 1341, s. 1343, s. 1347, s.
 1718  1349, or s. 1518 or 42 U.S.C. ss. 1320a-7b, relating to the
 1719  Medicaid program.
 1720         Section 17. Paragraph (q) of subsection (2) of section
 1721  499.01, Florida Statutes, is amended to read:
 1722         499.01 Permits.—
 1723         (2) The following permits are established:
 1724         (q) Device manufacturer permit.—A device manufacturer
 1725  permit is required for any person that engages in the
 1726  manufacture, repackaging, or assembly of medical devices for
 1727  human use in this state, except that a permit is not required
 1728  if:
 1729         1. The person does not manufacture, repackage, or assemble
 1730  any medical devices or components for such devices, except those
 1731  devices or components which are exempt from registration
 1732  pursuant to s. 499.015(8); or
 1733         2. The person is engaged only in manufacturing,
 1734  repackaging, or assembling a medical device pursuant to a
 1735  practitioner’s order for a specific patient.
 1736         a.1. A manufacturer or repackager of medical devices in
 1737  this state must comply with all appropriate state and federal
 1738  good manufacturing practices and quality system rules.
 1739         b.2. The department shall adopt rules related to storage,
 1740  handling, and recordkeeping requirements for manufacturers of
 1741  medical devices for human use.
 1742         Section 18. This act shall take effect July 1, 2010.

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