CSSSSB 41(HES): "An Act relating to medical care and crimes relating to medical care, including medical care and crimes relating to the medical assistance program."
00 CS FOR SPONSOR SUBSTITUTE FOR SENATE BILL NO. 41(HES) 01 "An Act relating to medical care and crimes relating to medical care, including medical 02 care and crimes relating to the medical assistance program." 03 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA: 04 * Section 1. AS 17.30.080 is amended to read: 05 Sec. 17.30.080. Unlawful administration, prescription, and dispensation of 06 controlled substances. (a) A controlled substance classified under federal law or in a 07 schedule set out in AS 11.71.140 - 11.71.190 may not be administered, prescribed, 08 dispensed, or distributed other than for a [MEDICAL] purpose that is solely medical. 09 A person otherwise authorized may not administer, prescribe, dispense, or 10 distribute a controlled substance classified under federal law or in a schedule set 11 out in AS 11.71.140 - 11.71.190 unless the substance is reasonably necessary for 12 treatment of a person's illness, injury, or medical condition, and the 13 administration, prescription, dispensing, or distribution may only be provided 14 within the usual course of professional health care practice or research and in
01 accordance with a standard of health care generally recognized and accepted 02 within the health care profession in the United States. 03 (b) A person who violates (a) of this section, or who otherwise manufactures, 04 distributes, dispenses, or conducts research with a controlled substance in the state 05 without fully complying with 21 U.S.C. 811 - 830 (Controlled Substances Act), and 06 regulations adopted under those sections, is guilty of misconduct involving a 07 controlled substance under AS 11.71.010 - 11.71.070 in the degree appropriate to the 08 circumstances as described in those sections. Upon filing a complaint, information, 09 presentment, or indictment charging a medical assistance provider with 10 misconduct involving a controlled substance under AS 11.71.140 - 11.71.190, the 11 attorney general shall, in writing, notify the commissioner of health and social 12 services of the filing. 13 * Sec. 2. AS 17.30.080 is amended by adding new subsections to read: 14 (c) Upon receiving a notice from the attorney general under (b) of this section, 15 the commissioner of health and social services shall immediately undertake a review 16 of all unpaid claims or requests for reimbursements attributable to services claimed to 17 have been provided by the person charged. 18 (d) In this section, "claims" and "medical assistance provider" have the 19 meanings given in AS 47.05.290. 20 * Sec. 3. AS 47.05 is amended by adding new sections to read: 21 Article 2. Medical Care Programs. 22 Sec. 47.05.200. Annual audits. (a) The department shall annually contract 23 for independent audits of a statewide sample of all medical assistance providers in 24 order to identify overpayments and violations of criminal statutes. The audits 25 conducted under this section may not be conducted by the department or employees of 26 the department. The number of audits under this section each year, as a total for the 27 medical assistance programs under AS 47.07 and AS 47.08, shall be 0.75 percent of 28 all enrolled providers under the programs, adjusted annually on July 1, as determined 29 by the department, except that the number of audits under this section may not be less 30 than 75. The audits under this section must include both on-site audits and desk audits 31 and must be of a variety of provider types. The department may not award a contract
01 under this subsection to an organization that does not retain persons with a significant 02 level of expertise and recent professional practice in the general areas of standard 03 accounting principles and financial auditing and in the specific areas of medical 04 records review, investigative research, and Alaska health care criminal law. The 05 contractor, in consultation with the commissioner, shall select the providers to be 06 audited and decide the ratio of desk audits and on-site audits to the total number 07 selected. 08 (b) Within 90 days after receiving each audit report from an audit conducted 09 under this section, the department shall begin administrative procedures to recoup 10 overpayments identified in the audits and shall allocate the reasonable and necessary 11 financial and human resources to ensure prompt recovery of overpayments unless the 12 attorney general has advised the commissioner in writing that a criminal investigation 13 of an audited provider has been or is about to be undertaken, in which case, the 14 commissioner shall hold the administrative procedure in abeyance until a final 15 charging decision by the attorney general has been made. The commissioner shall 16 provide copies of all audit reports to the attorney general so that the reports can be 17 screened for the purpose of bringing criminal charges. 18 (c) Each fiscal year, the state's share of recovered overpayments obtained 19 because of the required contract audits under this section shall be deposited with the 20 commissioner of revenue under AS 37.10.050 and separately accounted for by the 21 commissioner of administration under AS 37.05.142. The legislature may appropriate 22 a portion of the estimated balance in the account to the department to pay for the 23 annual audits described in this section. 24 (d) As a condition of obtaining payment under AS 47.07 and AS 47.08 and for 25 purposes of this section, a provider shall allow 26 (1) the department reasonable access to the records of medical 27 assistance recipients and providers; and 28 (2) audit and inspection of the records by state and federal agencies. 29 (e) This section does not preclude the department from performing audits that 30 are allowed or required under other laws. 31 Sec. 47.05.210. Medical assistance fraud. (a) A person commits the crime
01 of medical assistance fraud if the person 02 (1) knowingly submits or authorizes the submission of a claim to a 03 medical assistance agency for property, services, or a benefit with reckless disregard 04 that the claimant is not entitled to the property, services, or benefit; 05 (2) knowingly prepares or assists another person to prepare a claim for 06 submission to a medical assistance agency for property, services, or a benefit with 07 reckless disregard that the person being assisted is not entitled to the property, 08 services, or benefit; 09 (3) except as otherwise authorized under the medical assistance 10 program, confers, offers to confer, solicits, agrees to accept, or accepts property, 11 services, or a benefit 12 (A) to refer a medical assistance recipient to a health care 13 provider; or 14 (B) for providing health care to a medical assistance recipient if 15 the property, services, or benefit is in addition to payment by a medical 16 assistance agency; 17 (4) does not produce medical assistance records to a person authorized 18 to request the records; 19 (5) knowingly makes a false entry in or falsely alters a medical 20 assistance record; 21 (6) knowingly destroys, mutilates, suppresses, conceals, removes, or 22 otherwise impairs the verity, legibility, or availability of a medical assistance record; 23 or 24 (7) violates a provision of AS 47.07 or AS 47.08 or a regulation 25 adopted under AS 47.07 or AS 47.08. 26 (b) Medical assistance fraud under (a)(1), (2), or (3) of this section is 27 (1) a class B felony if the portion of the claim or claims submitted in 28 violation of (a)(1) or (2) of this section, or the value of the property, services, or 29 benefit that is in violation of (a)(3) of this section, is $25,000 or more; 30 (2) a class C felony if the portion of the claim or claims submitted in 31 violation of (a)(1) or (2) of this section, or the value of the property, services, or
01 benefit that is in violation of (a)(3) of this section, is $500 or more but less than 02 $25,000; 03 (3) a class A misdemeanor if the portion of the claim or claims 04 submitted in violation of (a)(1) or (2) of this section, or the value of the property, 05 services, or benefit that is in violation of (a)(3) of this section, is less than $500. 06 (c) Medical assistance fraud under (a)(4), (5), or (6) of this section is a class A 07 misdemeanor. 08 (d) Medical assistance fraud under (a)(7) of this section is a class B 09 misdemeanor. 10 Sec. 47.05.220. Notice of charges. Upon the filing of a complaint, 11 information, presentment, or indictment charging a medical assistance provider with a 12 crime under AS 47.05.210, the attorney general shall, in writing, notify the 13 commissioner of the filing. Upon receiving notice from the attorney general under 14 this section, the commissioner shall immediately undertake a review of all unpaid 15 claims or requests for reimbursements attributable to services claimed to have been 16 provided by the person charged. 17 Sec. 47.05.230. Determination of value; aggregation of amounts. In 18 AS 47.05.210, whenever it is necessary to determine the value of property, that value 19 shall be determined in accordance with AS 11.46.980. In determining the degree or 20 classification of a crime described under AS 47.05.210, amounts involved in criminal 21 acts committed under one course of conduct, whether from the same person or several 22 persons, shall be aggregated. 23 Sec. 47.05.240. Exclusion from medical assistance programs. (a) The 24 commissioner may exclude an applicant to or disenroll a medical assistance provider 25 in the medical assistance program in AS 47.07 or AS 47.08, or both, for a period of up 26 to 10 years following unconditional discharge on a conviction 27 (1) for medical assistance fraud under AS 47.05.210 or misconduct 28 involving a controlled substance under AS 11.71; or 29 (2) in a court of the United States or a court of another state or 30 territory, for a crime with elements substantially similar to the crimes included under 31 (1) of this subsection.
01 (b) After a period of exclusion under (a) of this section, an applicant may not 02 participate in a medical assistance program under AS 47.07 or AS 47.08 until the 03 applicant establishes to the commissioner by clear and convincing evidence that the 04 applicant possesses all required licenses and certificates and is qualified to participate. 05 Sec. 47.05.290. Definitions. In AS 47.05.200 - 47.05.290, 06 (1) "benefit" has the meaning given in AS 11.81.900; 07 (2) "claim," in addition to its usual meaning, also means a request for 08 payment for medical assistance services attempted to be provided, provided, or 09 claimed to have been provided to another, whether the request is in an electronic 10 format or paper format or both, made or submitted by a person or an organization that 11 is or claims to be a medical assistance provider; 12 (3) "commissioner" means the commissioner of health and social 13 services; 14 (4) "department" means the Department of Health and Social Services; 15 (5) "falsely alters" has the meaning given in AS 11.46.580; 16 (6) "knowingly" has the meaning given in AS 11.81.900; 17 (7) "makes a false entry" has the meaning given in AS 11.56.820; 18 (8) "medical assistance agency" means the department, an agency of 19 the department, and an agent, contractor, or designee of the department or of one of its 20 agencies that performs one or more of the activities of the department or an agency of 21 the department; 22 (9) "medical assistance program" means a program under AS 47.07 or 23 AS 47.08; 24 (10) "medical assistance provider" or "provider" means a person or 25 organization that provides, attempts to provide, or claims to have provided services or 26 products to a medical assistance recipient that may qualify for reimbursement under 27 AS 47.07 or AS 47.08 or a person or organization that participates in or has applied to 28 participate in a medical assistance program as a supplier of a service or product; 29 (11) "medical assistance recipient" means a person on whose behalf 30 another claims or receives a payment from a medical assistance agency, without 31 regard to whether the individual was eligible for benefits under a medical assistance
01 program; 02 (12) "medical assistance record" means records required to be kept by 03 state or federal law or regulation regarding claims to a medical assistance agency; 04 (13) "organization" has the meaning given in AS 11.81.900; 05 (14) "person" has the meaning given in AS 11.81.900; 06 (15) "property" has the meaning given in AS 11.81.900; 07 (16) "reckless disregard" means acting recklessly, as that term is 08 defined in AS 11.81.900; 09 (17) "services" means a health care benefit available to a medical 10 assistance recipient, including health care benefits provided, attempted to be provided, 11 or claimed to have been provided to another, by a medical assistance provider, or 12 "services" as defined in AS 11.81.900; 13 (18) "unconditional discharge" has the meaning given in 14 AS 12.55.185. 15 * Sec. 4. AS 47.07.010 is amended to read: 16 Sec. 47.07.010. Purpose. It is declared by the legislature as a matter of 17 public concern that the needy persons of this state who are eligible for health care at 18 public expense under this chapter should seek only [RECEIVE] uniform and high 19 quality medical care that is appropriate to their condition and cost-effective to the 20 state and receive that care, regardless of race, age, national origin, or economic 21 standing. It is equally a matter of public concern that providers of services under 22 this chapter should operate honestly, responsibly, and in accordance with 23 applicable laws and regulations in order to maintain the integrity and fiscal 24 viability of the state's medical assistance program, and that those who do not 25 operate in this manner should be held accountable for their conduct. It is vital 26 that the department administer this chapter in a manner that promotes effective, 27 long-term cost containment of the state's medical assistance expenditures while 28 providing medical care to recipients. Accordingly, this chapter authorizes the 29 department [DEPARTMENT OF HEALTH AND SOCIAL SERVICES] to apply for 30 participation in the national medical assistance program as provided for under 42 31 U.S.C. 1396 - 1396p (Title XIX, Social Security Act).
01 * Sec. 5. AS 47.07.074(a) is amended to read: 02 (a) As a condition of obtaining payment under AS 47.07.070, a health facility 03 shall allow 04 (1) the department and the commission reasonable access to the 05 [FINANCIAL] records of medical assistance recipients and providers 06 [BENEFICIARIES]; and 07 (2) audit and inspection of the [FINANCIAL] records by state and 08 federal agencies.