PRINTER'S NO. 1449
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
985
Session of
2020
INTRODUCED BY BOSCOLA, FARNESE, SCHWANK AND YUDICHAK,
JANUARY 15, 2020
REFERRED TO HEALTH AND HUMAN SERVICES, JANUARY 15, 2020
AN ACT
Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
act to consolidate, editorially revise, and codify the public
welfare laws of the Commonwealth," in fraud and abuse
control, further providing for definitions, for restrictions
on provider charges and payments, for provider prohibited
acts and criminal penalties and civil remedies and for venue
and limitations on actions.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The definitions of "provider" and "recipient" in
section 1401 of the act of June 13, 1967 (P.L.31, No.21), known
as the Human Services Code, are amended and the section is
amended by adding definitions to read:
Section 1401. Definitions.--The following words and phrases
when used in this article shall have, unless the context clearly
indicates otherwise, the meanings given to them in this section:
"Claim" means any request for payment.
* * *
"National Provider Identifier" or "NPI" means the national
unique health identifier for health care providers as defined in
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45 CFR 162.406 et seq. (relating to standard unique health
identifier for health care providers).
"Person" means an individual, medical facility or entity.
* * *
"Provider" [means any individual or medical facility which
signs an agreement with the department to participate in the
medical assistance program, including, but not limited to,
licensed practitioners, pharmacies, hospitals, nursing homes,
clinics, home health agencies and medical purveyors.] means a
person which provides goods or services under the medical
assistance program, whether or not there is an agreement with
the department to participate in the medical assistance program.
The term includes any person who has an agreement with either a
party to a provider agreement with the department or with a
medical assistance contractor or health maintenance
organization, under which the person agrees to provide goods or
services reimbursable under the medical assistance program.
* * *
"Recipient" [means an eligible person who receives medical
assistance from a participating provider.] means an individual
who receives goods or services from a provider under the medical
assistance program.
"Record" means:
(1) a medical, professional, financial or business record
relating to:
(i) the treatment or care of a recipient; or
(ii) goods or services provided to any recipient; and
(2) a record that is required by the rules or regulations of
the department to be retained for the medical assistance
program.
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* * *
"State Provider Identifier" or "SPI" means a State-issued
unique health identifier for persons providing goods or services
reimbursed by the medical assistance program, with no
intelligence about the person in the number.
"Statement or representation" means a communication that is
used to identify an item of goods or services for which
reimbursement is being sought under the medical assistance
program, or that is or may be used to determine a rate of
reimbursement under the medical assistance program.
Section 2. Section 1406 of the act is amended to read:
Section 1406. Restrictions on Provider Charges and
Payments.--(a) An individual seeking to provide goods or
services paid for, in whole or in part, with medical assistance
funds must have a National Provider Identifier or State Provider
Identifier. An individual who does not have an NPI must register
with the department and obtain an SPI prior to providing goods
or services under the medical assistance program.
(b) The department shall establish and mandate standardized
training for all persons providing services utilizing an SPI.
The standardized training for each specific type of service must
be completed prior to providing services. At a minimum, the
standardized training shall:
(1) be specific to the type of service being provided;
(2) focus on the required level or care the recipient is to
receive and what services are appropriately billable under that
program; and
(3) provide information on how to contact the appropriate
protective services agencies and where to report fraud within
the medical assistance program.
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(c) A claim submitted for medical assistance reimbursement,
whether to the department or any of its contractors, must
include:
(1) the NPI or SPI for the individual providing the good or
service;
(2) every date that a good or service was provided; and
(3) start and end times for each date of service. For per
diem claims, a start and end time for each date of service shall
not be required.
(d) All payments made to providers under the medical
assistance program shall constitute full reimbursement to the
provider for covered services rendered. Providers may not seek
or request supplemental or additional payments from recipients
for covered services unless authorized by law or regulation; nor
may a provider charge a recipient for other services to
supplement a covered service paid for by the department.
However, nothing in this act shall preclude charges for
uncovered services rendered to a recipient.
[(b)] (e) Charges made to the department by a provider for
covered services or items furnished shall not exceed, in any
case, the usual and customary charges made to the general public
by such provider for the same services or items.
(f) As used in this section, the following words and phrases
shall have the meanings given to them in this subsection unless
the context clearly indicates otherwise:
"Provider" shall mean a person that provides goods or
services that are reimbursed by the medical assistance program.
The term includes:
(1) a person with an agreement with the department to
participate in the medical assistance program;
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(2) an individual providing services reimbursed by the
medical assistance program; or
(3) a person who has an agreement with either a party to a
provider agreement with the department or with a medical
assistance contractor or health maintenance organization, under
which the person agrees to provide goods or services
reimbursable under the medical assistance program.
"Recipient" shall mean an individual who receives goods or
services from a provider under the medical assistance program.
Section 3. Section 1407(a), (b)(1) and (c)(3) of the act are
amended and the section is amended by adding a subsection to
read:
Section 1407. Provider Prohibited Acts, Criminal Penalties
and Civil Remedies.--(a) It shall be unlawful for any person
to[:
(1) Knowingly or intentionally present for allowance or
payment any false or fraudulent claim or cost report for
furnishing services or merchandise under medical assistance, or
to knowingly present for allowance or payment any claim or cost
report for medically unnecessary services or merchandise under
medical assistance, or to knowingly submit false information,
for the purpose of obtaining greater compensation than that to
which he is legally entitled for furnishing services or
merchandise under medical assistance, or to knowingly submit
false information for the purpose of obtaining authorization for
furnishing services or merchandise under medical assistance.]
knowingly or intentionally:
(1) (i) make or cause to be made a materially false,
fraudulent or misleading statement, claim or representation in
any record used by a person in connection with providing goods
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or services to any recipient under the medical assistance
program; or
(ii) submit or cause to be submitted false information for
the purpose of obtaining greater compensation than that to which
the person is legally entitled for furnishing goods or services
under the medical assistance program.
(2) Solicit or receive or to offer or pay any remuneration,
including any kickback, bribe or rebate, directly or indirectly,
in cash or in kind from or to any person in connection with the
furnishing of services or merchandise for which payment may be
in whole or in part under the medical assistance program or in
connection with referring an individual to a person for the
furnishing or arranging for the furnishing of any services or
merchandise for which payment may be made in whole or in part
under the medical assistance program.
(3) Submit or cause to be submitted a duplicate claim for
services, supplies or equipment for which the provider has
already received or claimed reimbursement from any source.
(4) Submit or cause to be submitted a claim for services,
supplies or equipment which were not rendered to a recipient.
(5) Submit or cause to be submitted a claim for services,
supplies or equipment which includes costs or charges not
related to such services, supplies or equipment rendered to the
recipient.
(6) Submit or cause to be submitted a claim or refer a
recipient to another provider by referral, order or
prescription, for services, supplies or equipment which are not
documented in the record in the prescribed manner and are of
little or no benefit to the recipient, are below the accepted
medical treatment standards, or are unneeded by the recipient.
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(7) Submit or cause to be submitted a claim which
misrepresents the description of services, supplies or equipment
dispensed or provided; the dates of services; the identity of
the recipient; the identity of the attending, prescribing or
referring practitioner; or the identity of the actual provider.
(8) Submit or cause to be submitted a claim for
reimbursement for a service, charge or item at a fee or charge
which is higher than the provider's usual and customary charge
to the general public for the same service or item.
(9) Submit or cause to be submitted a claim for a service or
item which was not rendered by the provider.
(10) Dispense, render or provide a service or item without a
practitioner's written order and the consent of the recipient,
except in emergency situations, or submit a claim for a service
or item which was dispensed, or provided without the consent of
the recipient, except in emergency situations.
(11) Except in emergency situations, dispense, render or
provide a service or item to a patient claiming to be a
recipient without making a reasonable effort to ascertain by
verification through a current medical assistance identification
card, that the person or patient is, in fact, a recipient who is
eligible on the date of service and without another available
medical resource.
(12) Enter into an agreement, combination or conspiracy to
obtain or aid another to obtain reimbursement or payments for
which there is not entitlement.
(13) Make a false statement in the application for
enrollment as a provider.
(14) Commit any of the prohibited acts described in section
1403(d)(1), (2), (4) and (5).
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(15) Submit or cause to be submitted any record for the
purposes of obtaining reimbursement from the medical assistance
program during any time period when the person is excluded or
precluded from participation in the medical assistance program
or when the person is on the Federal list of excluded
individuals and entities.
(b) (1) [A person who violates any provision of subsection
(a), excepting subsection (a)(11), is guilty of a felony of the
third degree for each such violation with a maximum penalty of
fifteen thousand dollars ($15,000) and seven years imprisonment.
A violation of subsection (a) shall be deemed to continue so
long as the course of conduct or the defendant's complicity
therein continues; the offense is committed when the course of
conduct or complicity of the defendant therein is terminated in
accordance with the provisions of 42 Pa.C.S. § 5552(d) (relating
to other offenses). Whenever any person has been previously
convicted in any state or Federal court of conduct that would
constitute a violation of subsection (a), a subsequent
allegation, indictment or information under subsection (a) shall
be classified as a felony of the second degree with a maximum
penalty of twenty-five thousand dollars ($25,000) and ten years
imprisonment.] (i) A person who violates subsection (a)(1),
(2), (3), (4), (5), (6), (7), (8), (9), (10), (11), (12), (13)
or (14) is guilty of:
(A) A felony of the second degree if the amount of excess
benefits or payments, whether claimed or actually paid, is over
$100,000 or if the person has a prior conviction in any Federal
or State court for conduct that would constitute a violation of
subsection (a).
(B) A felony of the third degree if the amount of excess of
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benefits or payments, whether claimed or actually paid, is over
$2,000 but less than $100,000.
(C) A misdemeanor of the first degree if the amount of
excess benefits or payments, whether claimed or actually paid,
is less than $2,000.
(ii) A person who violates subsection (a)(15) if guilty of a
felony of the second degree.
* * *
(b.1) Continuing course of conduct or complicity.--A
violation of subsection (a) shall be deemed to continue so long
as the course of conduct or the defendant's complicity in the
conduct continues. An offense is committed when the course of
conduct or complicity of the defendant in the conduct is
terminated as provided under 42 Pa.C.S. § 5552(d) (relating to
other offenses).
(c) * * *
(3) [Notice of any action taken by the department against a
provider pursuant to clauses (1) and (2) will be forwarded by
the department to the Medicaid Fraud Control Unit of the
Department of Justice and to the appropriate licensing board of
the Department of State for appropriate action, if any. In
addition, the department will forward to the Medicaid Fraud
Control Unit of the Department of Justice and the appropriate
Pennsylvania licensing board of the Department of State any
cases of suspected provider fraud.] The department shall forward
notice of any action taken by the department against a provider
under clauses (1) and (2) to the Medicaid Fraud Control Unit of
the Office of Attorney General and to the appropriate licensing
board of the Department of State for appropriate action, if any.
In addition, the department shall forward to the Medicaid Fraud
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Control Unit of the Office of Attorney General and the
appropriate Pennsylvania licensing board of the Department of
State any cases of suspected provider fraud.
Section 4. Section 1411 of the act is amended to read:
Section 1411. Venue and Limitations on Actions.--(a) Any
civil actions or criminal prosecutions brought pursuant to this
act for violations hereof shall be commenced within five years
of the date the violation or violations occur. [In addition, any
such actions or prosecutions may be brought in any county where
the offender has an office or place of business or where claims
and payments are processed by the Commonwealth or where
authorized by the Rules of the Pennsylvania Supreme Court.]
(b) Any civil actions or criminal prosecutions brought under
this act may be brought in:
(1) any county where the offender has an office or place of
business;
(2) any county where claims or payments are processed by the
Commonwealth or its contractor or subcontractor;
(3) the county in which the records were submitted or
processed;
(4) the county where the goods or services were alleged to
have been provided; or
(5) any county where authorized by the Pennsylvania Rules of
Criminal Procedure or other applicable rules of court.
Section 5. This act shall take effect in 60 days.
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