HB 332: "An Act relating to the procedure for medical assistance fraud investigation and the suspension of provider payment."
00 HOUSE BILL NO. 332 01 "An Act relating to the procedure for medical assistance fraud investigation and the 02 suspension of provider payment." 03 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA: 04 * Section 1. AS 47.05 is amended by adding a new section to read: 05 Sec. 47.05.235. Suspension of medical assistance payment for evidence of 06 fraud. (a) Except as provided in (k) and (l) of this section, the department shall 07 temporarily suspend all medical assistance payments to a provider after the 08 commissioner determines there is a credible allegation of fraud for which an 09 investigation is pending or the commissioner receives notice of charges against a 10 provider under AS 47.05.220. 11 (b) The department may suspend payments under this section without first 12 notifying the provider of its intention to suspend the payments. However, a provider 13 that is the subject of a suspension under this section may request a review by the 14 commissioner of the reasons for the suspension. The department shall adopt a
01 procedure for reviewing a suspension under this section. The procedure must include 02 notice of a suspension of payments within the following time frames: 03 (1) five days after suspending the payments, unless the attorney 04 general or another law enforcement agency requests in writing a temporary hold of 05 less than 30 days on the notice; or 06 (2) 30 days if requested in writing by the attorney general or another 07 law enforcement agency; a request under this paragraph may be renewed in writing, 08 but a delay in the notice may not exceed 90 days after the suspension. 09 (c) The notice under (b) of this section must include 10 (1) a statement that payments are being suspended under this section; 11 (2) a description of the general allegations, except that the department 12 may withhold specific information concerning an ongoing investigation; 13 (3) a statement that the suspension is temporary and a description of 14 the circumstances under which the suspension will be discontinued; 15 (4) when applicable, a description of the type or types of medical 16 assistance claims or business units of a provider that are affected by the suspension; 17 (5) information about the procedure for submitting written evidence 18 for consideration by the department and the administrative appeals process under 19 AS 44.64. 20 (d) The department shall discontinue a suspension after either 21 (1) the attorney general or another authorized law enforcement agency 22 determines that there is insufficient evidence of fraud by the provider; or 23 (2) legal proceedings related to the provider's alleged fraud are 24 completed. 25 (e) The department shall notify a provider in writing of discontinuation of a 26 suspension. 27 (f) Whenever an investigation by the department leads to the initiation of a 28 suspension of payments, in whole or part, the department shall make a fraud referral to 29 the attorney general or to another authorized law enforcement agency. A fraud referral 30 made under this subsection must 31 (1) be made in writing;
01 (2) be provided to the attorney general or another law enforcement 02 agency, if applicable, not later than the next business day after the suspension is 03 enacted; and 04 (3) conform to current fraud referral performance standards adopted by 05 the United States Secretary of Health and Human Services. 06 (g) If the attorney general or another law enforcement agency accepts for 07 investigation a fraud referral made under (f) of this section, the department may 08 continue the suspension of payments until the investigation and any associated 09 enforcement proceedings are completed. 10 (h) The department shall, on a quarterly basis, review current suspensions for 11 the purpose of monitoring the provider's and the department's compliance with the 12 procedures for suspension of payments under this section and determining the effect of 13 suspensions on recipient access to services. The review must include a request by the 14 department of written verification by the attorney general or another law enforcement 15 agency that a referral made under (f) of this section continues to be under an 16 investigation that warrants continuation of the suspension. 17 (i) If the attorney general or another law enforcement agency declines to 18 accept for investigation a fraud referral made under (f) of this section, the department 19 shall immediately discontinue a suspension imposed under this section unless the 20 department is authorized under another state or federal law to continue or impose a 21 suspension or make a fraud referral to another law enforcement agency. 22 (j) The department's decision not to suspend payments, or to suspend 23 payments only in part, under (k) or (l) of this section as a good cause exception does 24 not relieve the department of the obligation to refer a credible allegation of fraud as 25 provided in (f) of this section. 26 (k) If the department finds good cause not to suspend payments to, or not to 27 continue a suspension of payments previously imposed on, a provider under this 28 section, the department may decline to impose or continue a suspension. In this 29 section, good cause exists if 30 (1) the attorney general or another authorized law enforcement agency 31 has specifically requested that a suspension of payments not be imposed because a
01 suspension of payments may compromise or jeopardize an investigation; 02 (2) other available remedies implemented by the department more 03 effectively or quickly protect medical assistance funds; 04 (3) the department determines, based on the submission of written 05 evidence by the provider that is the subject of the suspension of payments, that the 06 suspension should be removed; 07 (4) recipient access to items or services would be jeopardized by a 08 payment suspension because either 09 (A) the provider is the sole community physician or the sole 10 source of essential specialized services in a community; or 11 (B) the provider serves a large number of beneficiaries within a 12 medically underserved area designated by the commissioner; 13 (5) the attorney general or another law enforcement agency declines to 14 verify that a matter continues to be under investigation under (h) of this section; 15 (6) the commissioner determines that the suspension of payments is 16 not in the best interests of the medical assistance program. 17 (l) The commissioner may find that good cause exists to suspend payments in 18 part, or to convert a payment suspension previously imposed in whole to apply only in 19 part, to a provider that is under investigation for a credible allegation of fraud if 20 (1) recipient access to items or services would be jeopardized as 21 provided in (k)(4) of this section; 22 (2) the commissioner determines, based on the submission of written 23 evidence by the provider that is the subject of a whole payment suspension, that the 24 suspension should apply only in part; 25 (3) the credible allegation focuses solely and definitively on only a 26 specific type of claim or arises from only a specific business unit of a provider and the 27 commissioner makes a finding in writing that a payment suspension in part would 28 effectively ensure that potentially fraudulent claims will not continue to be paid; 29 (4) the attorney general or another authorized law enforcement agency 30 declines to verify that a matter continues to be under investigation under (h) of this 31 section; or
01 (5) the commissioner determines that the suspension of payments only 02 in part is in the best interests of the medical assistance program. 03 (m) The department shall provide information to recipients who are patients of 04 a provider that is subject to a suspension under this section about the availability of 05 alternate providers or services. 06 (n) In this section, "provider" means a health care professional or a health care 07 facility authorized to provide services under the medical assistance program.