PRINTER'S NO. 3511

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 AND RADER, APRIL 3, 2020

organizations.

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

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.

(c) An agreement under subsection (a) shall require a

medical assistance managed care organization to comply with all

of the following:

(1) Cease to expend money from the medical assistance

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.

(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

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

(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.

(h) 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)

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.