98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB0071

 

Introduced 1/9/2013, by Rep. Kelly M. Cassidy

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Amends the Public Assistance Fraud Article of the Illinois Public Aid Code. Provides that (i) any person who knowingly obtains unauthorized medical benefits or causes to be obtained unauthorized medical benefits (rather than knowingly obtains unauthorized medical benefits) with or without use of a medical card; (ii) any vendor that knowingly assists or knowingly or willfully fails to prevent a person from committing specified violations; or (iii) any person (including a vendor, organization, agency, or other entity) that, in any matter related to the medical assistance program, knowingly or willfully falsifies, conceals, or omits by any trick, scheme, artifice, or device a material fact, or makes any false, fictitious, or fraudulent statement or representation, or makes or uses any false writing or document, knowing the same to contain any false, fictitious, or fraudulent statement or entry in connection with the provision of health care or related services commits medical assistance fraud. Sets forth conduct that constitutes managed health care fraud. Enhances the criminal penalty, from a Class A misdemeanor to a Class 4 felony, for any person, firm, corporation, association, agency, institution, or other legal entity that, in any matter related to a State or federally funded or mandated health plan, knowingly and willfully makes a false statement in connection with the provision of health care or related services. Provides that no person shall willfully obstruct criminal investigations of health care offenses and makes a violation a Class 4 felony. Effective immediately.


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CORRECTIONAL BUDGET AND IMPACT NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Sections 8A-2.5, 8A-13, and 8A-15 and by adding
6Section 8A-18 as follows:
 
7    (305 ILCS 5/8A-2.5)
8    Sec. 8A-2.5. Unauthorized use of medical assistance.
9    (a) Any person who knowingly uses, acquires, possesses, or
10transfers a medical card in any manner not authorized by law or
11by rules and regulations of the Illinois Department, or who
12knowingly alters a medical card, or who knowingly uses,
13acquires, possesses, or transfers an altered medical card, is
14guilty of a violation of this Article and shall be punished as
15provided in Section 8A-6.
16    (b) Any person who knowingly obtains unauthorized medical
17benefits or causes to be obtained unauthorized medical benefits
18with or without use of a medical card is guilty of a violation
19of this Article and shall be punished as provided in Section
208A-6.
21    (b-5) Any vendor that knowingly assists or knowingly or
22willfully fails to prevent a person from committing a violation
23under subsection (a) or (b) of this Section is guilty of a

 

 

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1violation of this Article and shall be punished as provided in
2Section 8A-6.
3    (b-6) Any person (including a vendor, organization,
4agency, or other entity) that, in any matter related to the
5medical assistance program, knowingly or willfully falsifies,
6conceals, or omits by any trick, scheme, artifice, or device a
7material fact, or makes any false, fictitious, or fraudulent
8statement or representation, or makes or uses any false writing
9or document, knowing the same to contain any false, fictitious,
10or fraudulent statement or entry in connection with the
11provision of health care or related services, is guilty of a
12violation of this Article and shall be punished as provided in
13Section 8A-6.
14    (c) The Department may seek to recover any and all State
15and federal monies for which it has improperly and erroneously
16paid benefits as a result of a fraudulent action and any civil
17penalties authorized in this Section. Pursuant to Section
1811-14.5 of this Code, the Department may determine the monetary
19value of benefits improperly and erroneously received. The
20Department may recover the monies paid for such benefits and
21interest on that amount at the rate of 5% per annum for the
22period from which payment was made to the date upon which
23repayment is made to the State. Prior to the recovery of any
24amount paid for benefits allegedly obtained by fraudulent
25means, the recipient or payee of such benefits shall be
26afforded an opportunity for a hearing after reasonable notice.

 

 

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1The notice shall be served personally or by certified or
2registered mail or as otherwise provided by law upon the
3parties or their agents appointed to receive service of process
4and shall include the following:
5        (1) A statement of the time, place and nature of the
6    hearing.
7        (2) A statement of the legal authority and jurisdiction
8    under which the hearing is to be held.
9        (3) A reference to the particular Sections of the
10    substantive and procedural statutes and rules involved.
11        (4) Except where a more detailed statement is otherwise
12    provided for by law, a short and plain statement of the
13    matters asserted, the consequences of a failure to respond,
14    and the official file or other reference number.
15        (5) A statement of the monetary value of the benefits
16    fraudulently received by the person accused.
17        (6) A statement that, in addition to any other
18    penalties provided by law, a civil penalty in an amount not
19    to exceed $2,000 may be imposed for each fraudulent claim
20    for benefits or payments.
21        (7) A statement providing that the determination of the
22    monetary value may be contested by petitioning the
23    Department for an administrative hearing within 30 days
24    from the date of mailing the notice.
25        (8) The names and mailing addresses of the
26    administrative law judge, all parties, and all other

 

 

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1    persons to whom the agency gives notice of the hearing
2    unless otherwise confidential by law.
3    An opportunity shall be afforded all parties to be
4represented by legal counsel and to respond and present
5evidence and argument.
6    Unless precluded by law, disposition may be made of any
7contested case by stipulation, agreed settlement, consent
8order, or default.
9    Any final order, decision, or other determination made,
10issued or executed by the Director under the provisions of this
11Article whereby any person is aggrieved shall be subject to
12review in accordance with the provisions of the Administrative
13Review Law, and the rules adopted pursuant thereto, which shall
14apply to and govern all proceedings for the judicial review of
15final administrative decisions of the Director.
16    Upon entry of a final administrative decision for repayment
17of any benefits obtained by fraudulent means, or for any civil
18penalties assessed, a lien shall attach to all property and
19assets of such person, firm, corporation, association, agency,
20institution, vendor, or other legal entity until the judgment
21is satisfied.
22    Within 18 months of the effective date of this amendatory
23Act of the 96th General Assembly, the Department of Healthcare
24and Family Services will report to the General Assembly on the
25number of fraud cases identified and pursued, and the fines
26assessed and collected. The report will also include the

 

 

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1Department's analysis as to the use of private sector resources
2to bring action, investigate, and collect monies owed.
3(Source: P.A. 96-1501, eff. 1-25-11; 97-23, eff. 1-1-12.)
 
4    (305 ILCS 5/8A-13)
5    Sec. 8A-13. Managed health care fraud.
6    (a) As used in this Section, "health plan" means any of the
7following:
8        (1) Any health care reimbursement plan sponsored
9    wholly or partially by the State.
10        (2) Any private insurance carrier, health care
11    cooperative or alliance, health maintenance organization,
12    insurer, organization, entity, association, affiliation,
13    or person that contracts to provide or provides goods or
14    services that are reimbursed by or are a required benefit
15    of a health benefits program funded wholly or partially by
16    the State.
17        (3) Anyone who provides or contracts to provide goods
18    and services to an entity described in paragraph (1) or (2)
19    of this subsection.
20    For purposes of item (2) in subsection (b),
21"representation" and "statement" include, but are not limited
22to, reports, claims, certifications, acknowledgments and
23ratifications of financial information, enrollment claims,
24demographic statistics, encounter data, health services
25available or rendered, and the qualifications of person

 

 

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1rendering health care and ancillary services.
2    (b) Any person, firm, corporation, association, agency,
3institution, or other legal entity that, with the intent to
4obtain benefits or payments under this Code to which the person
5or entity is not entitled or in a greater amount than that to
6which the person or entity is entitled, knowingly, or
7willfully: executes or conspires to execute a scheme or
8artifice
9        (1) executes or conspires to execute a scheme or
10    artifice to defraud any State or federally funded or
11    mandated health plan in connection with the delivery of or
12    payment for health care benefits, items, or services; , or
13        (2) executes or conspires to execute a scheme or
14    artifice to obtain by means of false or fraudulent
15    pretense, representation, statement, or promise money or
16    anything of value in connection with the delivery of or
17    payment for health care benefits, items, or services that
18    are in whole or in part paid for, reimbursed, or subsidized
19    by, or are a required benefit of, a State or federally
20    funded or mandated health plan;
21        (3) falsifies, conceals, or covers up by any trick,
22    scheme, or device a material fact in connection with the
23    delivery of or payment for health care benefits, items, or
24    services that are in whole or in part paid for or
25    reimbursed by a State or federal health plan;
26        (4) makes any materially false, fictitious, or

 

 

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1    fraudulent statements or representations, or makes or uses
2    any materially false writing or document knowing the same
3    to contain any materially false, fictitious, or fraudulent
4    statement or entry, in connection with the delivery of or
5    payment for health care benefits, items, or services that
6    are in whole or in part paid for or reimbursed by a State
7    or federal health plan; or
8        (5) makes or uses any false writing or document knowing
9    the same to contain any materially false, fictitious, or
10    fraudulent statement or entry in connection with the
11    delivery of or payment for health care benefits, items, or
12    services that are in whole or in part paid for or
13    reimbursed by a State or federal health plan
14is guilty of a violation of this Article and shall be punished
15as provided in Section 8A-6.
16(Source: P.A. 90-538, eff. 12-1-97.)
 
17    (305 ILCS 5/8A-15)
18    Sec. 8A-15. False statements relating to health care
19delivery. Any person, firm, corporation, association, agency,
20institution, or other legal entity that, in any matter related
21to a State or federally funded or mandated health plan,
22knowingly and wilfully falsifies, conceals, or omits by any
23trick, scheme, artifice, or device a material fact, or makes
24any false, fictitious, or fraudulent statement or
25representation, or makes or uses any false writing or document,

 

 

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1knowing the same to contain any false, fictitious, or
2fraudulent statement or entry in connection with the provision
3of health care or related services, is guilty of a Class 4
4felony A misdemeanor.
5(Source: P.A. 90-538, eff. 12-1-97.)
 
6    (305 ILCS 5/8A-18 new)
7    Sec. 8A-18. Obstruction of criminal investigations of
8health care offenses.
9    (a) Whoever willfully prevents, obstructs, misleads,
10delays or attempts to prevent, obstruct, mislead, or delay the
11communication of information or records relating to a violation
12of a federal or State health care offense to a criminal
13investigator is guilty of a Class 4 felony.
14    (b) As used in this Section, "criminal investigator" means
15any individual duly authorized by a department or agency of the
16United States or of this State to conduct or engage in
17investigations for prosecutions for violations of health care
18offenses.
 
19    Section 99. Effective date. This Act takes effect upon
20becoming law.

 

 

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1 INDEX
2 Statutes amended in order of appearance
3    305 ILCS 5/8A-2.5
4    305 ILCS 5/8A-13
5    305 ILCS 5/8A-15
6    305 ILCS 5/8A-18 new