Regular Session 2019-2020 House Bill 2355 P.N. 3914

PRIOR PRINTER'S NO. 3511

PRINTER'S NO. 3914

THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

No.

2355

Session of

2020

INTRODUCED BY SANKEY, GROVE, KAUFER, GAYDOS, OWLETT, THOMAS,

JONES, MILLARD, BERNSTINE, RYAN, WHEELAND, SAYLOR, COX, MOUL,

KEEFER, KLUNK, DUSH, B. MILLER, RADER AND NELSON,

APRIL 3, 2020

AS REPORTED FROM COMMITTEE ON HUMAN SERVICES, HOUSE OF

REPRESENTATIVES, AS AMENDED, JUNE 9, 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 public assistance,

providing for duties of medical assistance managed care

organizations MEDICAL ASSISTANCE MANAGED CARE ORGANIZATION

RATE SETTING.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1. The act of June 13, 1967 (P.L.31, No.21), known

as the Human Services Code, is amended by adding a section to

read:

Section 449.1. Duties of Medical Assistance Managed Care

Organizations.--(a) No less than ninety days after the

effective date of this section, a medical assistance managed

care organization that provides services or seeks to provide

services under the medical assistance program shall enter into

an agreement with the department as specified under this

section.

<--

(b) An agreement under subsection (a) shall authorize the

department to recover any loss incurred by the department as a

result of a medical assistance managed care organization's

failure to do any of the following:

(1) Comply with the terms of the medical assistance managed

care organization's contract with the department.

(2) Comply with Federal or State regulations regarding

services provided by the medical assistance managed care

organization through the medical assistance program.

medical assistance managed care organization to comply with all

of the following:

(1) Cease to expend money from the medical assistance

program to make payments for claims that constitute provider

preventable conditions that occurred during inpatient

procedures.

(2) Annually review all inpatient services to determine if

money paid under the medical assistance program was prohibited

because the payments were for claims that constitute provider

preventable conditions.

(d) The department shall require a medical assistance

managed care organization to document and review all of the

following:

(1) Claims for inpatient services that were paid under the

medical assistance program to determine if the payments were for

claims that constitute provider preventable conditions.

(2) Claims for behavioral services that were paid under the

medical assistance program to determine if the payments were for

claims that constitute provider preventable conditions.

(e) Upon request by the department, a medical assistance

20200HB2355PN3914 - 2 -

managed care organization shall provide the department with any

documents associated with the medical assistance managed care

organization's review under subsection (d).

(f) Upon examining documents provided under subsection (e),

if the department determines that a medical assistance managed

care organization has not kept adequate records to stop the

payment of claims that constitute provider preventable

conditions, the department shall impose a fine of no less than

0.5% and no more than 5% of the total claims from medical

assistance managed care organizations from the medical

assistance program.

(g) Upon examining documents provided under subsection (e),

if the department determines that a medical assistance managed

care organization paid claims that constitute provider

preventable conditions, the department shall have the following

duties:

(1) If a claim which constituted a provider preventable

condition was paid by the medical assistance program under the

fee for service model, the department shall require the medical

assistance managed care organization to reimburse the department

for an amount equal to the total amount of payments for claims

that constitute provider preventable conditions.

(2) If a medical assistance managed care organization fails

to disclose payments for claims that constitute provider

preventable conditions, the department shall:

(i) require the medical assistance managed care organization

and the medical assistance managed care organization to

reimburse the department for the total amount of payments for

claims that constitute provider preventable conditions; and

(ii) impose an additional fine of up to 5% of the total

20200HB2355PN3914 - 3 -

amount of payments for claims that constitute provider

preventable conditions made by the medical assistance managed

care organization.

(3) If a claim which constituted a provider preventable

condition was paid by the medical assistance program as a

capitated payment, the department shall adjust the capitated

payment rate for the medicaid managed care organization that

paid the claim for a provider preventable condition during the

next fiscal year.

SECTION 449.1. MEDICAL ASSISTANCE MANAGED CARE ORGANIZATION

RATE SETTING.--(A) THE DEPARTMENT SHALL ANNUALLY ADJUST THE

MEDICAL ASSISTANCE MANAGED CARE ORGANIZATION FINANCIAL REPORTING

THAT IS USED AS THE BASIS OF RATE SETTING BY THE VALUE OF

PROVIDER-PREVENTABLE CONDITIONS IN NO LESS THAN FACILITY PLACE

OF SERVICE PAID BY THE MEDICAL ASSISTANCE MANAGED CARE

ORGANIZATION TO ENSURE THAT FEDERAL AND STATE FUNDS ARE NOT USED

TO PAY FOR IMPROPER PAYMENTS.

(B) THE DEPARTMENT SHALL ANNUALLY REPORT THE VALUE OF

ADJUSTMENTS BY THE MEDICAL ASSISTANCE MANAGED CARE ORGANIZATION

UNDER SUBSECTION (A) AS PART OF THE REPORTS REQUIRED UNDER

ARTICLE V-A.

(h) (C) As used in this section, the following words and

phrases shall have the meanings given to them in this

subsection:

"Medical assistance managed care organization" means a

Medicaid managed care organization as defined in section 1903(m)

(1)(A) of the Social Security Act (49 Stat. 620, 42 U.S.C. §

1903(m)(1)(A)) that is a party to a Medicaid managed care

contract with the department to provide physical or behavioral

health services.

20200HB2355PN3914 - 4 -

<--

"Provider preventable conditions" means any of the following:

(1) A condition acquired in any inpatient setting that is

considered to have a high cost or occur in a high volume.

(2) A surgical or invasive procedure performed on the wrong

patient.

(3) A surgical or invasive procedure performed on the wrong

body part of a patient.

"PROVIDER-PREVENTABLE CONDITIONS" MEANS ANY CONDITIONS

OCCURRING IN A HEALTH CARE SETTING THAT MEET THE FOLLOWING

CRITERIA:

(1) IS IDENTIFIED IN THE STATE PLAN IN LINE WITH THE FEE-

FOR-SERVICE MODEL.

(2) HAS BEEN FOUND BY THE COMMONWEALTH, BASED UPON A REVIEW

OF MEDICAL LITERATURE BY QUALIFIED PROFESSIONALS, TO BE

REASONABLY PREVENTABLE THROUGH THE APPLICATION OF PROCEDURES

SUPPORTED BY EVIDENCE-BASED GUIDELINES.

(3) HAS A NEGATIVE CONSEQUENCE FOR THE PATIENT.

(4) IS AUDITABLE.

(5) INCLUDES, AT A MINIMUM, ANY OF THE FOLLOWING:

(I) A WRONG SURGICAL OR OTHER INVASIVE PROCEDURE PERFORMED

ON A PATIENT.

(II) A SURGICAL OR OTHER INVASIVE PROCEDURE PERFORMED ON THE

WRONG BODY PART.

(III) A SURGICAL OR OTHER INVASIVE PROCEDURE PERFORMED ON

THE WRONG PATIENT.

Section 2. This act shall take effect in 60 days.

20200HB2355PN3914 - 5 -

<--