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91_SB0754
LRB9105850JSpc
1 AN ACT to create the Medical Fraud Enforcement Act.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the
5 Medical Fraud Enforcement Act.
6 Section 5. Definitions.
7 "Insurance fraud" means the presentation of any written
8 or oral statement, document, or claim or the preparation of
9 any statement, document, or claim with the intention that the
10 statement, document, or claim will be presented, that the
11 person knew or should have known contained materially false,
12 incomplete, or misleading information concerning any of the
13 following:
14 (1) An application for the issuance of an insurance
15 policy or managed care plan.
16 (2) A claim for payment, reimbursement, or benefits
17 payable under an insurance policy, provider network
18 arrangement, or managed care plan.
19 (3) Encounter or other data for the purpose of
20 justifying capitation payments of other financial
21 arrangements under an insurance policy, provider network
22 arrangement, or managed care plan.
23 (4) A payment made in accordance with the terms of
24 an insurance policy, provider network arrangement, or
25 managed care plan.
26 (5) A premium on an insurance policy or managed
27 care plan.
28 (6) The rating of an insurance policy or managed
29 care plan.
30 "Medical Fraud" means the presentation of any written or
31 oral statement, document, or claim, or the preparation of any
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1 such statement, document, or claim with the intention that
2 the statement, document, or claim will be presented, that the
3 person knew or should have known contained materially false,
4 incomplete, or misleading information, concerning any of the
5 following:
6 (1) An application for the issuance of an insurance
7 policy or managed care plan.
8 (2) A statement or other description of medical
9 services rendered including, but not limited to, a
10 medical record, a completed or partially completed HCFA
11 1500 form, a completed or partially completed UB-92 form,
12 a procedure or diagnosis coding, or any other statement
13 of charges or services rendered.
14 (3) A claim for payment, reimbursement, or benefits
15 payable under an insurance policy, provider network
16 arrangement, or managed care plan.
17 (4) Encounter, qualitative, utilization, or other
18 data representation of medical practice activities and
19 patterns.
20 (5) A payment made in accordance with the terms of
21 an insurance policy, provider network arrangement, or
22 managed care plan.
23 (6) A premium on an insurance policy or managed
24 care plan.
25 (7) The rating of an insurance policy or managed
26 care plan.
27 Section 10. Medical Fraud Enforcement Fund. There is
28 created the Medical Fraud Enforcement Fund as a special Fund
29 in the State treasury. Subject to appropriation, the moneys
30 in the Fund shall be used to fund the Attorney General's
31 vigorous efforts to fight medical fraud.
32 Section 15. Disposition of fines imposed for medical
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1 fraud.
2 (a) If a court finds that a person has committed a
3 medical fraud, the court shall impose a fine equal to at
4 least 2 times the amount of the medical fraud. In the case
5 of duplicate fines for a single violation or series of
6 violations, the fines shall not be cumulative, but the
7 greater fine shall be imposed.
8 (b) The court shall determine the amount of the person's
9 medical fraud as follows:
10 (1) the aggregate dollar amount of all medical
11 bills, insurance claims, capitation payments, or other
12 financial instruments received, submitted for payment, or
13 submitted to justify payment, directly or indirectly, as
14 part of the medical fraud; and
15 (2) the aggregate expense to the government to
16 investigate and prosecute the medical fraud.
17 (c) The circuit clerk of the court imposing a fine for
18 medical fraud pursuant to this Act shall collect and transmit
19 the moneys received under this Act to the State Treasurer for
20 deposit into the Medical Fraud Enforcement Fund.
21 (d) The State Treasurer shall deposit the amount of all
22 fines under this Act into the Medical Fraud Enforcement Fund.
23 Section 20. Medical fraud assessment.
24 (a) If a court imposes a fine for medical fraud, the
25 court shall, in addition to the fines imposed pursuant to
26 this Act, impose a medical fraud assessment of not less than
27 75% of the amount of the fine.
28 (b) If any deposit is made for an offense subject to
29 this Act, the person making the deposit shall also deposit a
30 sufficient amount to include the medical fraud assessment
31 prescribed in this Section. If the deposit is forfeited for
32 whatever reason, the corresponding amount of the medical
33 fraud assessment shall also be forfeited and shall
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1 immediately be transmitted to the State Treasurer.
2 (c) The circuit clerk of the court imposing any medical
3 assessment pursuant to this Section shall collect and
4 transmit the medical fraud assessments to the State
5 Treasurer.
6 (d) The State Treasurer shall deposit the amount of all
7 medical fraud assessments into the Medical Fraud Enforcement
8 Fund.
9 Section 25. Medical fraud restitution payment.
10 (a) If a court imposes a fine for medical fraud, the
11 court shall impose a medical fraud restitution payment equal
12 to the following:
13 (1) the aggregate dollar amount of all medical
14 bills, insurance claims, capitation payments, or other
15 financial instruments received, submitted for payment, or
16 submitted to justify payment, directly or indirectly, as
17 part of the medical fraud; and
18 (2) the aggregate cost to the payer, including
19 attorney's fees, to enforce the provisions of a private
20 contract violated by the person in perpetrating the
21 medical fraud. The amount shall be determined by the
22 court, but the court shall consider all evidence
23 submitted by the payer to justify its costs, including
24 attorney's fees.
25 (b) If a fine is suspended only in part, the medical
26 fraud restitution payment shall not be reduced.
27 (c) If any deposit is made for an offense to which this
28 Section applies, the person making the deposit shall also
29 deposit a sufficient amount to include the medical fraud
30 restitution payment prescribed in this Section. If the
31 deposit is forfeited, the amount of the medical fraud
32 restitution payment shall be transmitted to the State
33 Treasurer.
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1 (d) The circuit clerk of the court shall collect and
2 transmit to the State Treasurer the medical fraud restitution
3 payment and other amounts collected pursuant to this Section.
4 (e) The State Treasurer shall deposit the amount of the
5 restitution payments into the Medical Fraud Enforcement Fund.
6 (f) In the case of medical fraud court action, the
7 minimum amounts required for mandatory assessments and
8 restitution under this Section shall not be considered in
9 determining the amount of the medical fraud fine.
10 Section 30. Injunction.
11 (a) The Attorney General shall seek and may obtain an
12 injunction that prohibits a person from engaging in the
13 practice or doing any acts that constitute medical fraud.
14 (b) The court may enter any order or judgement that is
15 necessary to:
16 (1) prevent any act or practice that constitutes
17 medical fraud;
18 (2) return any moneys, interest, or real or
19 personal property that was acquired by an act or practice
20 that constitutes medical fraud; and
21 (3) enforce medical fraud fines, assessments, and
22 orders of restitution, which may include expenses
23 incurred and paid by an insurer in connection with any
24 medical evaluation or treatment services.
25 Section 35. Civil immunity exemption; reports of
26 insurance fraud.
27 (a) A person who, absent malice, files a report with or
28 furnishes information concerning alleged, suspected,
29 anticipated, or completed insurance fraud is immune from
30 civil liability for his or her acts or omissions in filing
31 the report or furnishing the information to any of the
32 following or to their agents, employees, or designees:
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1 (1) The Department of Insurance.
2 (2) A law enforcement officer.
3 (3) The National Association of Insurance
4 Commissioners.
5 (4) Any governmental agency established to detect
6 and prevent insurance fraud.
7 (5) Any insurer or authorized representative of an
8 insurer for the purpose of detecting or preventing
9 insurance fraud.
10 (b) Any information furnished by an insurer in response
11 to a report or information furnished under subsection (a) is
12 confidential and may be made public only if required in a
13 civil or criminal action.
14 (c) If a civil action is commenced against a person for
15 damages related to the filing of a report or the furnishing
16 of information under subsection (a) and the court determines
17 that the person is immune from civil liability for his or her
18 acts or omissions in filing the report or furnishing the
19 information, the person filing the report or furnishing the
20 information shall be entitled to recover costs, including
21 reasonable attorney's fees.
22 Section 40. Public disclosure of acts or suspected acts
23 of medical fraud.
24 (a) The circuit clerk of the court having imposed a
25 fine, assessment, or requirement of restitution against a
26 person for medical fraud shall immediately make such
27 information available to the Department of Professional
28 Regulation.
29 (b) The Department of Professional Regulation shall make
30 a summary of all acts of medical fraud available to the
31 public through at least all of the following means:
32 (1) a publicly accessible, government Internet
33 site;
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1 (2) a written notification to the Department of
2 Insurance, the Department of Public Health, the National
3 Practitioner's Data Bank, and the Federation of State
4 Medical Boards; and
5 (3) a written publication, updated at least
6 monthly, made available to the public upon request.
7 (c) The Department of Professional Regulation shall
8 protect the privacy of any innocent person not party to the
9 medical fraud.
10 (d) Information made available pursuant to subsection
11 (b) may be removed by the Department of Professional
12 Regulation only upon death of the person having committed the
13 act or acts of medical fraud.
14 (e) All licensed providers practicing in this State are
15 required to provide to each patient of the provider a written
16 disclosure of the right to file a suspected medical fraud
17 complaint.
18 (f) The disclosure required under subsection (e) shall
19 be provided to the patient each time a statement or other
20 description of medical services rendered is provided to the
21 patient, including cases where the statement is submitted to
22 an insurer for insurance benefits pursuant to an assignment
23 of benefits.
24 (g) The disclosure required under subsection (e) shall
25 include at least all of the following:
26 (1) the name, license, physical address, phone
27 number, and electronic mail address if any, of the
28 provider;
29 (2) the name, government agency, physical address,
30 phone number, and electronic mail address if any, of the
31 Attorney General's office to which a complaint may be
32 forwarded; and
33 (3) a brief statement explaining the citizen's
34 right to, and process to, file a complaint of a suspected
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1 medical fraud, including a description of the civil
2 immunity provided in Section 35 of this Act.
3 (h) The Department of Professional Regulation shall, by
4 rule, promulgate the language of a standard statement that
5 shall be used by all licensed providers in this State to
6 satisfy the requirements of subsections (e), (f) and (g). At
7 its discretion, the Department's rule may provide for
8 different language for different provider types.
9 Section 90. The State Finance Act is amended by adding
10 Section 5.490 as follows:
11 (30 ILCS 105/5.490 new)
12 Sec. 5.490. The Medical Fraud Enforcement Fund.