Medicaid Overpayment and Prescription Drug Abuse
- Seeks to address recipient fraud by limiting, restricting, or suspending Medicaid eligibility for recipients convicted of a fraudulent act under or against a federal health care program.
- There is no prohibition against such action in federal law provided the sanction is tied to a conviction associated with fraud of a federal health care program.
- Mandates enrollment in a drug therapy management or disease management program for those recipients identified as over utilizers or abusers of services or medicines.
- This change would reduce or eliminate improper diversion or resale of drugs by recipients.
- Implements amnesty programs designed to allow Medicaid providers the opportunity to voluntarily repay overpayments with little or no penalty to the provider.
- This change would serve as an incentive for repayment by providers otherwise reluctant to come forward fearing penalties and sanctions from AHCA.
- Grants AHCA authority, at its discretion, to implement amnesty programs.
- The bill also does the following:
- AHCA may withhold payment to a provider upon receipt of evidence that would give rise to the need to do so regardless of whether there are ongoing legal proceedings related to that evidence.
- Providers have an obligation with regard to submitting claims to the Medicaid program and further clarifies claims may be denied if not so submitted.
- Clarifies that AHCA may deny payments where the goods or services were furnished by a suspended or terminated provider.
- Clarifies that the Agency may impose a sanction when the provider submits false or a pattern of erroneous claims even when those claims do not result in an overpayment
- Clarifies that the requirement for peer review for physician claims applies to only those claims that involved medical judgment
- Clarifies that the Agency is only required to report sanctions related to certain violations to the licensing entity
Agency for Health Care Administration Legislative Proposal 2004
Origination Date August 27, 2003
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