305 ILCS 5/12-4.25

Current through Public Act 103-1052

Section 305 ILCS 5/12-4.25 - Medical assistance program; vendor participation

(A) The Illinois Department may deny, suspend, or terminate the eligibility of any person, firm, corporation, association, agency, institution or other legal entity to participate as a vendor of goods or services to recipients under the medical assistance program under Article V, or may exclude any such person or entity from participation as such a vendor, and may deny, suspend, or recover payments, if after reasonable notice and opportunity for a hearing the Illinois Department finds:

(a) Such vendor is not complying with the Department's policy or rules and regulations, or with the terms and conditions prescribed by the Illinois Department in its vendor agreement, which document shall be developed by the Department as a result of negotiations with each vendor category, including physicians, hospitals, long term care facilities, pharmacists, optometrists, podiatric physicians, and dentists setting forth the terms and conditions applicable to the participation of each vendor group in the program; or

(b) Such vendor has failed to keep or make available for inspection, audit or copying, after receiving a written request from the Illinois Department, such records regarding payments claimed for providing services. This section does not require vendors to make available patient records of patients for whom services are not reimbursed under this Code; or

(c) Such vendor has failed to furnish any information requested by the Department regarding payments for providing goods or services; or

(d) Such vendor has knowingly made, or caused to be made, any false statement or representation of a material fact in connection with the administration of the medical assistance program; or

(e) Such vendor has furnished goods or services to a recipient which are (1) in excess of need, (2) harmful, or (3) of grossly inferior quality, all of such determinations to be based upon competent medical judgment and evaluations; or

(f) The vendor; a person with management responsibility for a vendor; an officer or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate vendor; an owner of a sole proprietorship which is a vendor; or a partner in a partnership which is a vendor, either:

(1) was previously terminated, suspended, or excluded from participation in the Illinois medical assistance program, or was terminated, suspended, or excluded from participation in another state or federal medical assistance or health care program; or

(2) was a person with management responsibility for a vendor previously terminated, suspended, or excluded from participation in the Illinois medical assistance program, or terminated, suspended, or excluded from participation in another state or federal medical assistance or health care program during the time of conduct which was the basis for that vendor's termination, suspension, or exclusion; or

(3) was an officer, or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate or limited liability company vendor previously terminated, suspended, or excluded from participation in the Illinois medical assistance program, or terminated, suspended, or excluded from participation in a state or federal medical assistance or health care program during the time of conduct which was the basis for that vendor's termination, suspension, or exclusion; or

(4) was an owner of a sole proprietorship or partner of a partnership previously terminated, suspended, or excluded from participation in the Illinois medical assistance program, or terminated, suspended, or excluded from participation in a state or federal medical assistance or health care program during the time of conduct which was the basis for that vendor's termination, suspension, or exclusion; or

(f-1) Such vendor has a delinquent debt owed to the Illinois Department; or

(g) The vendor; a person with management responsibility for a vendor; an officer or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate or limited liability company vendor; an owner of a sole proprietorship which is a vendor; or a partner in a partnership which is a vendor, either:

(1) has engaged in practices prohibited by applicable federal or State law or regulation; or

(2) was a person with management responsibility for a vendor at the time that such vendor engaged in practices prohibited by applicable federal or State law or regulation; or

(3) was an officer, or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a vendor at the time such vendor engaged in practices prohibited by applicable federal or State law or regulation; or

(4) was an owner of a sole proprietorship or partner of a partnership which was a vendor at the time such vendor engaged in practices prohibited by applicable federal or State law or regulation; or

(h) The direct or indirect ownership of the vendor (including the ownership of a vendor that is a sole proprietorship, a partner's interest in a vendor that is a partnership, or ownership of 5% or more of the shares of stock or other evidences of ownership in a corporate vendor) has been transferred by an individual who is terminated, suspended, or excluded or barred from participating as a vendor to the individual's spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin, or relative by marriage.

(A-5) The Illinois Department may deny, suspend, or terminate the eligibility of any person, firm, corporation, association, agency, institution, or other legal entity to participate as a vendor of goods or services to recipients under the medical assistance program under Article V, or may exclude any such person or entity from participation as such a vendor, if, after reasonable notice and opportunity for a hearing, the Illinois Department finds that the vendor; a person with management responsibility for a vendor; an officer or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate vendor; an owner of a sole proprietorship that is a vendor; or a partner in a partnership that is a vendor has been convicted of an offense based on fraud or willful misrepresentation related to any of the following:

(1) The medical assistance program under Article V of this Code.

(2) A medical assistance or health care program in another state.

(3) The Medicare program under Title XVIII of the Social Security Act.

(4) The provision of health care services.

(5) A violation of this Code, as provided in Article VIIIA, or another state or federal medical assistance program or health care program.

(A-10) The Illinois Department may deny, suspend, or terminate the eligibility of any person, firm, corporation, association, agency, institution, or other legal entity to participate as a vendor of goods or services to recipients under the medical assistance program under Article V, or may exclude any such person or entity from participation as such a vendor, if, after reasonable notice and opportunity for a hearing, the Illinois Department finds that (i) the vendor, (ii) a person with management responsibility for a vendor, (iii) an officer or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, (iv) an owner of a sole proprietorship that is a vendor, or (v) a partner in a partnership that is a vendor has been convicted of an offense related to any of the following:

(1) Murder.

(2) A Class X felony under the Criminal Code of 1961 or the Criminal Code of 2012.

(3) Sexual misconduct that may subject recipients to an undue risk of harm.

(4) A criminal offense that may subject recipients to an undue risk of harm.

(5) A crime of fraud or dishonesty.

(6) A crime involving a controlled substance.

(7) A misdemeanor relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct related to a health care program.

(A-15) The Illinois Department may deny the eligibility of any person, firm, corporation, association, agency, institution, or other legal entity to participate as a vendor of goods or services to recipients under the medical assistance program under Article V if, after reasonable notice and opportunity for a hearing, the Illinois Department finds:

(1) The applicant or any person with management responsibility for the applicant; an officer or member of the board of directors of an applicant; an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor applicant; an owner of a sole proprietorship applicant; a partner in a partnership applicant; or a technical or other advisor to an applicant has a debt owed to the Illinois Department, and no payment arrangements acceptable to the Illinois Department have been made by the applicant.

(2) The applicant or any person with management responsibility for the applicant; an officer or member of the board of directors of an applicant; an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor applicant; an owner of a sole proprietorship applicant; a partner in a partnership vendor applicant; or a technical or other advisor to an applicant was (i) a person with management responsibility, (ii) an officer or member of the board of directors of an applicant, (iii) an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, (iv) an owner of a sole proprietorship, (v) a partner in a partnership vendor, (vi) a technical or other advisor to a vendor, during a period of time where the conduct of that vendor resulted in a debt owed to the Illinois Department, and no payment arrangements acceptable to the Illinois Department have been made by that vendor.

(3) There is a credible allegation of the use, transfer, or lease of assets of any kind to an applicant from a current or prior vendor who has a debt owed to the Illinois Department, no payment arrangements acceptable to the Illinois Department have been made by that vendor or the vendor's alternate payee, and the applicant knows or should have known of such debt.

(4) There is a credible allegation of a transfer of management responsibilities, or direct or indirect ownership, to an applicant from a current or prior vendor who has a debt owed to the Illinois Department, and no payment arrangements acceptable to the Illinois Department have been made by that vendor or the vendor's alternate payee, and the applicant knows or should have known of such debt.

(5) There is a credible allegation of the use, transfer, or lease of assets of any kind to an applicant who is a spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, relative by marriage, nephew, cousin, or relative of a current or prior vendor who has a debt owed to the Illinois Department and no payment arrangements acceptable to the Illinois Department have been made.

(6) There is a credible allegation that the applicant's previous affiliations with a provider of medical services that has an uncollected debt, a provider that has been or is subject to a payment suspension under a federal health care program, or a provider that has been previously excluded from participation in the medical assistance program, poses a risk of fraud, waste, or abuse to the Illinois Department.

As used in this subsection, "credible allegation" is defined to include an allegation from any source, including, but not limited to, fraud hotline complaints, claims data mining, patterns identified through provider audits, civil actions filed under the Illinois False Claims Act, and law enforcement investigations. An allegation is considered to be credible when it has indicia of reliability.

(B) The Illinois Department shall deny, suspend or terminate the eligibility of any person, firm, corporation, association, agency, institution or other legal entity to participate as a vendor of goods or services to recipients under the medical assistance program under Article V, or may exclude any such person or entity from participation as such a vendor:

(1) immediately, if such vendor is not properly licensed, certified, or authorized;

(2) within 30 days of the date when such vendor's professional license, certification or other authorization has been refused renewal, restricted, revoked, suspended, or otherwise terminated; or

(3) if such vendor has been convicted of a violation of this Code, as provided in Article VIIIA.

(C) Upon termination, suspension, or exclusion of a vendor of goods or services from participation in the medical assistance program authorized by this Article, a person with management responsibility for such vendor during the time of any conduct which served as the basis for that vendor's termination, suspension, or exclusion is barred from participation in the medical assistance program.

Upon termination, suspension, or exclusion of a corporate vendor, the officers and persons owning, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in the vendor during the time of any conduct which served as the basis for that vendor's termination, suspension, or exclusion are barred from participation in the medical assistance program. A person who owns, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a terminated, suspended, or excluded vendor may not transfer his or her ownership interest in that vendor to his or her spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin, or relative by marriage.

Upon termination, suspension, or exclusion of a sole proprietorship or partnership, the owner or partners during the time of any conduct which served as the basis for that vendor's termination, suspension, or exclusion are barred from participation in the medical assistance program. The owner of a terminated, suspended, or excluded vendor that is a sole proprietorship, and a partner in a terminated, suspended, or excluded vendor that is a partnership, may not transfer his or her ownership or partnership interest in that vendor to his or her spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin, or relative by marriage.

A person who owns, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate or limited liability company vendor who owes a debt to the Department, if that vendor has not made payment arrangements acceptable to the Department, shall not transfer his or her ownership interest in that vendor, or vendor assets of any kind, to his or her spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin, or relative by marriage.

Rules adopted by the Illinois Department to implement these provisions shall specifically include a definition of the term "management responsibility" as used in this Section. Such definition shall include, but not be limited to, typical job titles, and duties and descriptions which will be considered as within the definition of individuals with management responsibility for a provider.

A vendor or a prior vendor who has been terminated, excluded, or suspended from the medical assistance program, or from another state or federal medical assistance or health care program, and any individual currently or previously barred from the medical assistance program, or from another state or federal medical assistance or health care program, as a result of being an officer or a person owning, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate or limited liability company vendor during the time of any conduct which served as the basis for that vendor's termination, suspension, or exclusion, may be required to post a surety bond as part of a condition of enrollment or participation in the medical assistance program. The Illinois Department shall establish, by rule, the criteria and requirements for determining when a surety bond must be posted and the value of the bond.

A vendor or a prior vendor who has a debt owed to the Illinois Department and any individual currently or previously barred from the medical assistance program, or from another state or federal medical assistance or health care program, as a result of being an officer or a person owning, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in that corporate or limited liability company vendor during the time of any conduct which served as the basis for the debt, may be required to post a surety bond as part of a condition of enrollment or participation in the medical assistance program. The Illinois Department shall establish, by rule, the criteria and requirements for determining when a surety bond must be posted and the value of the bond.

(D) If a vendor has been suspended from the medical assistance program under Article V of the Code, the Director may require that such vendor correct any deficiencies which served as the basis for the suspension. The Director shall specify in the suspension order a specific period of time, which shall not exceed one year from the date of the order, during which a suspended vendor shall not be eligible to participate. At the conclusion of the period of suspension the Director shall reinstate such vendor, unless he finds that such vendor has not corrected deficiencies upon which the suspension was based.

If a vendor has been terminated, suspended, or excluded from the medical assistance program under Article V, such vendor shall be barred from participation for at least one year, except that if a vendor has been terminated, suspended, or excluded based on a conviction of a violation of Article VIIIA or a conviction of a felony based on fraud or a willful misrepresentation related to (i) the medical assistance program under Article V, (ii) a federal or another state's medical assistance or health care program, or (iii) the provision of health care services, then the vendor shall be barred from participation for 5 years or for the length of the vendor's sentence for that conviction, whichever is longer. At the end of one year a vendor who has been terminated, suspended, or excluded may apply for reinstatement to the program. Upon proper application to be reinstated such vendor may be deemed eligible by the Director providing that such vendor meets the requirements for eligibility under this Code. If such vendor is deemed not eligible for reinstatement, he shall be barred from again applying for reinstatement for one year from the date his application for reinstatement is denied.

A vendor whose termination, suspension, or exclusion from participation in the Illinois medical assistance program under Article V was based solely on an action by a governmental entity other than the Illinois Department may, upon reinstatement by that governmental entity or upon reversal of the termination, suspension, or exclusion, apply for rescission of the termination, suspension, or exclusion from participation in the Illinois medical assistance program. Upon proper application for rescission, the vendor may be deemed eligible by the Director if the vendor meets the requirements for eligibility under this Code.

If a vendor has been terminated, suspended, or excluded and reinstated to the medical assistance program under Article V and the vendor is terminated, suspended, or excluded a second or subsequent time from the medical assistance program, the vendor shall be barred from participation for at least 2 years, except that if a vendor has been terminated, suspended, or excluded a second time based on a conviction of a violation of Article VIIIA or a conviction of a felony based on fraud or a willful misrepresentation related to (i) the medical assistance program under Article V, (ii) a federal or another state's medical assistance or health care program, or (iii) the provision of health care services, then the vendor shall be barred from participation for life. At the end of 2 years, a vendor who has been terminated, suspended, or excluded may apply for reinstatement to the program. Upon application to be reinstated, the vendor may be deemed eligible if the vendor meets the requirements for eligibility under this Code. If the vendor is deemed not eligible for reinstatement, the vendor shall be barred from again applying for reinstatement for 2 years from the date the vendor's application for reinstatement is denied.

(E) The Illinois Department may recover money improperly or erroneously paid, or overpayments, either by setoff, crediting against future billings or by requiring direct repayment to the Illinois Department. The Illinois Department may suspend or deny payment, in whole or in part, if such payment would be improper or erroneous or would otherwise result in overpayment.

(1) Payments may be suspended, denied, or recovered from a vendor or alternate payee: (i) for services rendered in violation of the Illinois Department's provider notices, statutes, rules, and regulations; (ii) for services rendered in violation of the terms and conditions prescribed by the Illinois Department in its vendor agreement; (iii) for any vendor who fails to grant the Office of Inspector General timely access to full and complete records, including, but not limited to, records relating to recipients under the medical assistance program for the most recent 6 years, in accordance with Section 140.28 of Title 89 of the Illinois Administrative Code, and other information for the purpose of audits, investigations, or other program integrity functions, after reasonable written request by the Inspector General; this subsection (E) does not require vendors to make available the medical records of patients for whom services are not reimbursed under this Code or to provide access to medical records more than 6 years old; (iv) when the vendor has knowingly made, or caused to be made, any false statement or representation of a material fact in connection with the administration of the medical assistance program; or (v) when the vendor previously rendered services while terminated, suspended, or excluded from participation in the medical assistance program or while terminated or excluded from participation in another state or federal medical assistance or health care program.

(2) Notwithstanding any other provision of law, if a vendor has the same taxpayer identification number (assigned under Section 6109 of the Internal Revenue Code of 1986) as is assigned to a vendor with past-due financial obligations to the Illinois Department, the Illinois Department may make any necessary adjustments to payments to that vendor in order to satisfy any past-due obligations, regardless of whether the vendor is assigned a different billing number under the medical assistance program.

(E-5) Civil monetary penalties.

(1) As used in this subsection (E-5):

(a) "Knowingly" means that a person, with respect to information: (i) has actual knowledge of the information; (ii) acts in deliberate ignorance of the truth or falsity of the information; or (iii) acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.

(b) "Overpayment" means any funds that a person receives or retains from the medical assistance program to which the person, after applicable reconciliation, is not entitled under this Code.

(c) "Remuneration" means the offer or transfer of items or services for free or for other than fair market value by a person; however, remuneration does not include items or services of a nominal value of no more than $10 per item or service, or $50 in the aggregate on an annual basis, or any other offer or transfer of items or services as determined by the Department.

(d) "Should know" means that a person, with respect to information: (i) acts in deliberate ignorance of the truth or falsity of the information; or (ii) acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.

(2) Any person (including a vendor, provider, organization, agency, or other entity, or an alternate payee thereof, but excluding a recipient) who:

(a) knowingly presents or causes to be presented to an officer, employee, or agent of the State, a claim that the Department determines:

(i) is for a medical or other item or service that the person knows or should know was not provided as claimed, including any person who engages in a pattern or practice of presenting or causing to be presented a claim for an item or service that is based on a code that the person knows or should know will result in a greater payment to the person than the code the person knows or should know is applicable to the item or service actually provided;

(ii) is for a medical or other item or service and the person knows or should know that the claim is false or fraudulent;

(iii) is presented for a vendor physician's service, or an item or service incident to a vendor physician's service, by a person who knows or should know that the individual who furnished, or supervised the furnishing of, the service:

(AA) was not licensed as a physician;

(BB) was licensed as a physician but such license had been obtained through a misrepresentation of material fact (including cheating on an examination required for licensing); or

(CC) represented to the patient at the time the service was furnished that the physician was certified in a medical specialty by a medical specialty board, when the individual was not so certified;

(iv) is for a medical or other item or service furnished during a period in which the person was excluded from the medical assistance program or a federal or state health care program under which the claim was made pursuant to applicable law; or

(v) is for a pattern of medical or other items or services that a person knows or should know are not medically necessary;

(b) knowingly presents or causes to be presented to any person a request for payment which is in violation of the conditions for receipt of vendor payments under the medical assistance program under Section 11-13 of this Code;

(c) knowingly gives or causes to be given to any person, with respect to medical assistance program coverage of inpatient hospital services, information that he or she knows or should know is false or misleading, and that could reasonably be expected to influence the decision when to discharge such person or other individual from the hospital;

(d) in the case of a person who is not an organization, agency, or other entity, is excluded from participating in the medical assistance program or a federal or state health care program and who, at the time of a violation of this subsection (E-5):

(i) retains a direct or indirect ownership or control interest in an entity that is participating in the medical assistance program or a federal or state health care program, and who knows or should know of the action constituting the basis for the exclusion; or

(ii) is an officer or managing employee of such an entity;

(e) offers or transfers remuneration to any individual eligible for benefits under the medical assistance program that such person knows or should know is likely to influence such individual to order or receive from a particular vendor, provider, practitioner, or supplier any item or service for which payment may be made, in whole or in part, under the medical assistance program;

(f) arranges or contracts (by employment or otherwise) with an individual or entity that the person knows or should know is excluded from participation in the medical assistance program or a federal or state health care program, for the provision of items or services for which payment may be made under such a program;

(g) commits an act described in subsection (b) or (c) of Section 8A-3;

(h) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim for payment for items and services furnished under the medical assistance program;

(i) fails to grant timely access, upon reasonable request (as defined by the Department by rule), to the Inspector General, for the purpose of audits, investigations, evaluations, or other statutory functions of the Inspector General of the Department;

(j) orders or prescribes a medical or other item or service during a period in which the person was excluded from the medical assistance program or a federal or state health care program, in the case where the person knows or should know that a claim for such medical or other item or service will be made under such a program;

(k) knowingly makes or causes to be made any false statement, omission, or misrepresentation of a material fact in any application, bid, or contract to participate or enroll as a vendor or provider of services or a supplier under the medical assistance program;

(l) knows of an overpayment and does not report and return the overpayment to the Department in accordance with paragraph (6);

shall be subject, in addition to any other penalties that may be prescribed by law, to a civil money penalty of not more than $10,000 for each item or service (or, in cases under subparagraph (c), $15,000 for each individual with respect to whom false or misleading information was given; in cases under subparagraph (d), $10,000 for each day the prohibited relationship occurs; in cases under subparagraph (g), $50,000 for each such act; in cases under subparagraph (h), $50,000 for each false record or statement; in cases under subparagraph (i), $15,000 for each day of the failure described in such subparagraph; or in cases under subparagraph (k), $50,000 for each false statement, omission, or misrepresentation of a material fact). In addition, such a person shall be subject to an assessment of not more than 3 times the amount claimed for each such item or service in lieu of damages sustained by the State because of such claim (or, in cases under subparagraph (g), damages of not more than 3 times the total amount of remuneration offered, paid, solicited, or received, without regard to whether a portion of such remuneration was offered, paid, solicited, or received for a lawful purpose; or in cases under subparagraph (k), an assessment of not more than 3 times the total amount claimed for each item or service for which payment was made based upon the application, bid, or contract containing the false statement, omission, or misrepresentation of a material fact).

(3) In addition, the Director or his or her designee may make a determination in the same proceeding to exclude, terminate, suspend, or bar the person from participation in the medical assistance program.

(4) The Illinois Department may seek the civil monetary penalties and exclusion, termination, suspension, or barment identified in this subsection (E-5). Prior to the imposition of any penalties or sanctions, the affected person shall be afforded an opportunity for a hearing after reasonable notice. The Department shall establish hearing procedures by rule.

(5) Any final order, decision, or other determination made, issued, or executed by the Director under the provisions of this subsection (E-5), whereby a person is aggrieved, shall be subject to review in accordance with the provisions of the Administrative Review Law, and the rules adopted pursuant thereto, which shall apply to and govern all proceedings for the judicial review of final administrative decisions of the Director.

(6)

(a) If a person has received an overpayment, the person shall:

(i) report and return the overpayment to the Department at the correct address; and

(ii) notify the Department in writing of the reason for the overpayment.

(b) An overpayment must be reported and returned under subparagraph (a) by the later of:

(i) the date which is 60 days after the date on which the overpayment was identified; or

(ii) the date any corresponding cost report is due, if applicable.

(E-10) A vendor who disputes an overpayment identified as part of a Department audit shall utilize the Department's self-referral disclosure protocol as set forth under this Code to identify, investigate, and return to the Department any undisputed audit overpayment amount. Unless the disputed overpayment amount is subject to a fraud payment suspension, or involves a termination sanction, the Department shall defer the recovery of the disputed overpayment amount up to one year after the date of the Department's final audit determination, or earlier, or as required by State or federal law. If the administrative hearing extends beyond one year, and such delay was not caused by the request of the vendor, then the Department shall not recover the disputed overpayment amount until the date of the final administrative decision. If a final administrative decision establishes that the disputed overpayment amount is owed to the Department, then the amount shall be immediately due to the Department. The Department shall be entitled to recover interest from the vendor on the overpayment amount from the date of the overpayment through the date the vendor returns the overpayment to the Department at a rate not to exceed the Wall Street Journal Prime Rate, as published from time to time, but not to exceed 5%. Any interest billed by the Department shall be due immediately upon receipt of the Department's billing statement.

(F) The Illinois Department may withhold payments to any vendor or alternate payee prior to or during the pendency of any audit or proceeding under this Section, and through the pendency of any administrative appeal or administrative review by any court proceeding. The Illinois Department shall state by rule with as much specificity as practicable the conditions under which payments will not be withheld under this Section. Payments may be denied for bills submitted with service dates occurring during the pendency of a proceeding, after a final decision has been rendered, or after the conclusion of any administrative appeal, where the final administrative decision is to terminate, exclude, or suspend eligibility to participate in the medical assistance program. The Illinois Department shall state by rule with as much specificity as practicable the conditions under which payments will not be denied for such bills. The Illinois Department shall state by rule a process and criteria by which a vendor or alternate payee may request full or partial release of payments withheld under this subsection. The Department must complete a proceeding under this Section in a timely manner.

Notwithstanding recovery allowed under subsection (E) or this subsection (F), the Illinois Department may withhold payments to any vendor or alternate payee who is not properly licensed, certified, or in compliance with State or federal agency regulations. Payments may be denied for bills submitted with service dates occurring during the period of time that a vendor is not properly licensed, certified, or in compliance with State or federal regulations. Facilities licensed under the Nursing Home Care Act shall have payments denied or withheld pursuant to subsection (I) of this Section.

(F-5) The Illinois Department may temporarily withhold payments to a vendor or alternate payee if any of the following individuals have been indicted or otherwise charged under a law of the United States or this or any other state with an offense that is based on alleged fraud or willful misrepresentation on the part of the individual related to (i) the medical assistance program under Article V of this Code, (ii) a federal or another state's medical assistance or health care program, or (iii) the provision of health care services:

(1) If the vendor or alternate payee is a corporation: an officer of the corporation or an individual who owns, either directly or indirectly, 5% or more of the shares of stock or other evidence of ownership of the corporation.

(2) If the vendor is a sole proprietorship: the owner of the sole proprietorship.

(3) If the vendor or alternate payee is a partnership: a partner in the partnership.

(4) If the vendor or alternate payee is any other business entity authorized by law to transact business in this State: an officer of the entity or an individual who owns, either directly or indirectly, 5% or more of the evidences of ownership of the entity.

If the Illinois Department withholds payments to a vendor or alternate payee under this subsection, the Department shall not release those payments to the vendor or alternate payee while any criminal proceeding related to the indictment or charge is pending unless the Department determines that there is good cause to release the payments before completion of the proceeding. If the indictment or charge results in the individual's conviction, the Illinois Department shall retain all withheld payments, which shall be considered forfeited to the Department. If the indictment or charge does not result in the individual's conviction, the Illinois Department shall release to the vendor or alternate payee all withheld payments.

(F-10) If the Illinois Department establishes that the vendor or alternate payee owes a debt to the Illinois Department, and the vendor or alternate payee subsequently fails to pay or make satisfactory payment arrangements with the Illinois Department for the debt owed, the Illinois Department may seek all remedies available under the law of this State to recover the debt, including, but not limited to, wage garnishment or the filing of claims or liens against the vendor or alternate payee.

(F-15) Enforcement of judgment.

(1) Any fine, recovery amount, other sanction, or costs imposed, or part of any fine, recovery amount, other sanction, or cost imposed, remaining unpaid after the exhaustion of or the failure to exhaust judicial review procedures under the Illinois Administrative Review Law is a debt due and owing the State and may be collected using all remedies available under the law.

(2) After expiration of the period in which judicial review under the Illinois Administrative Review Law may be sought for a final administrative decision, unless stayed by a court of competent jurisdiction, the findings, decision, and order of the Director may be enforced in the same manner as a judgment entered by a court of competent jurisdiction.

(3) In any case in which any person or entity has failed to comply with a judgment ordering or imposing any fine or other sanction, any expenses incurred by the Illinois Department to enforce the judgment, including, but not limited to, attorney's fees, court costs, and costs related to property demolition or foreclosure, after they are fixed by a court of competent jurisdiction or the Director, shall be a debt due and owing the State and may be collected in accordance with applicable law. Prior to any expenses being fixed by a final administrative decision pursuant to this subsection (F-15), the Illinois Department shall provide notice to the individual or entity that states that the individual or entity shall appear at a hearing before the administrative hearing officer to determine whether the individual or entity has failed to comply with the judgment. The notice shall set the date for such a hearing, which shall not be less than 7 days from the date that notice is served. If notice is served by mail, the 7-day period shall begin to run on the date that the notice was deposited in the mail.

(4) Upon being recorded in the manner required by Article XII of the Code of Civil Procedure or by the Uniform Commercial Code, a lien shall be imposed on the real estate or personal estate, or both, of the individual or entity in the amount of any debt due and owing the State under this Section. The lien may be enforced in the same manner as a judgment of a court of competent jurisdiction. A lien shall attach to all property and assets of such person, firm, corporation, association, agency, institution, or other legal entity until the judgment is satisfied.

(5) The Director may set aside any judgment entered by default and set a new hearing date upon a petition filed at any time (i) if the petitioner's failure to appear at the hearing was for good cause, or (ii) if the petitioner established that the Department did not provide proper service of process. If any judgment is set aside pursuant to this paragraph (5), the hearing officer shall have authority to enter an order extinguishing any lien which has been recorded for any debt due and owing the Illinois Department as a result of the vacated default judgment.

(G) The provisions of the Administrative Review Law, as now or hereafter amended, and the rules adopted pursuant thereto, shall apply to and govern all proceedings for the judicial review of final administrative decisions of the Illinois Department under this Section. The term "administrative decision" is defined as in Section 3-101 of the Code of Civil Procedure.

(G-5) Vendors who pose a risk of fraud, waste, abuse, or harm.

(1) Notwithstanding any other provision in this Section, the Department may terminate, suspend, or exclude vendors who pose a risk of fraud, waste, abuse, or harm from participation in the medical assistance program prior to an evidentiary hearing but after reasonable notice and opportunity to respond as established by the Department by rule.

(2) Vendors who pose a risk of fraud, waste, abuse, or harm shall submit to a fingerprint-based criminal background check on current and future information available in the State system and current information available through the Federal Bureau of Investigation's system by submitting all necessary fees and information in the form and manner prescribed by the Illinois State Police. The following individuals shall be subject to the check:

(A) In the case of a vendor that is a corporation, every shareholder who owns, directly or indirectly, 5% or more of the outstanding shares of the corporation.

(B) In the case of a vendor that is a partnership, every partner.

(C) In the case of a vendor that is a sole proprietorship, the sole proprietor.

(D) Each officer or manager of the vendor.

Each such vendor shall be responsible for payment of the cost of the criminal background check.

(3) Vendors who pose a risk of fraud, waste, abuse, or harm may be required to post a surety bond. The Department shall establish, by rule, the criteria and requirements for determining when a surety bond must be posted and the value of the bond.

(4) The Department, or its agents, may refuse to accept requests for authorization from specific vendors who pose a risk of fraud, waste, abuse, or harm, including prior-approval and post-approval requests, if:

(A) the Department has initiated a notice of termination, suspension, or exclusion of the vendor from participation in the medical assistance program; or

(B) the Department has issued notification of its withholding of payments pursuant to subsection (F-5) of this Section; or

(C) the Department has issued a notification of its withholding of payments due to reliable evidence of fraud or willful misrepresentation pending investigation.

(5) As used in this subsection, the following terms are defined as follows:

(A) "Fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person. It includes any act that constitutes fraud under applicable federal or State law.

(B) "Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices and that result in an unnecessary cost to the medical assistance program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the medical assistance program. Abuse does not include diagnostic or therapeutic measures conducted primarily as a safeguard against possible vendor liability.

(C) "Waste" means the unintentional misuse of medical assistance resources, resulting in unnecessary cost to the medical assistance program. Waste does not include diagnostic or therapeutic measures conducted primarily as a safeguard against possible vendor liability.

(D) "Harm" means physical, mental, or monetary damage to recipients or to the medical assistance program.

(G-6) The Illinois Department, upon making a determination based upon information in the possession of the Illinois Department that continuation of participation in the medical assistance program by a vendor would constitute an immediate danger to the public, may immediately suspend such vendor's participation in the medical assistance program without a hearing. In instances in which the Illinois Department immediately suspends the medical assistance program participation of a vendor under this Section, a hearing upon the vendor's participation must be convened by the Illinois Department within 15 days after such suspension and completed without appreciable delay. Such hearing shall be held to determine whether to recommend to the Director that the vendor's medical assistance program participation be denied, terminated, suspended, placed on provisional status, or reinstated. In the hearing, any evidence relevant to the vendor constituting an immediate danger to the public may be introduced against such vendor; provided, however, that the vendor, or his or her counsel, shall have the opportunity to discredit, impeach, and submit evidence rebutting such evidence.

(H) Nothing contained in this Code shall in any way limit or otherwise impair the authority or power of any State agency responsible for licensing of vendors.

(I) Based on a finding of noncompliance on the part of a nursing home with any requirement for certification under Title XVIII or XIX of the Social Security Act ( 42 U.S.C. Sec. 1395 et seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois Department may impose one or more of the following remedies after notice to the facility:

(1) Termination of the provider agreement.

(2) Temporary management.

(3) Denial of payment for new admissions.

(4) Civil money penalties.

(5) Closure of the facility in emergency situations or transfer of residents, or both.

(6) State monitoring.

(7) Denial of all payments when the U.S. Department of Health and Human Services has imposed this sanction.

The Illinois Department shall by rule establish criteria governing continued payments to a nursing facility subsequent to termination of the facility's provider agreement if, in the sole discretion of the Illinois Department, circumstances affecting the health, safety, and welfare of the facility's residents require those continued payments. The Illinois Department may condition those continued payments on the appointment of temporary management, sale of the facility to new owners or operators, or other arrangements that the Illinois Department determines best serve the needs of the facility's residents.

Except in the case of a facility that has a right to a hearing on the finding of noncompliance before an agency of the federal government, a facility may request a hearing before a State agency on any finding of noncompliance within 60 days after the notice of the intent to impose a remedy. Except in the case of civil money penalties, a request for a hearing shall not delay imposition of the penalty. The choice of remedies is not appealable at a hearing. The level of noncompliance may be challenged only in the case of a civil money penalty. The Illinois Department shall provide by rule for the State agency that will conduct the evidentiary hearings.

The Illinois Department may collect interest on unpaid civil money penalties.

The Illinois Department may adopt all rules necessary to implement this subsection (I).

(J) The Illinois Department, by rule, may permit individual practitioners to designate that Department payments that may be due the practitioner be made to an alternate payee or alternate payees.

(a) Such alternate payee or alternate payees shall be required to register as an alternate payee in the Medical Assistance Program with the Illinois Department.

(b) If a practitioner designates an alternate payee, the alternate payee and practitioner shall be jointly and severally liable to the Department for payments made to the alternate payee. Pursuant to subsection (E) of this Section, any Department action to suspend or deny payment or recover money or overpayments from an alternate payee shall be subject to an administrative hearing.

(c) Registration as an alternate payee or alternate payees in the Illinois Medical Assistance Program shall be conditional. At any time, the Illinois Department may deny or cancel any alternate payee's registration in the Illinois Medical Assistance Program without cause. Any such denial or cancellation is not subject to an administrative hearing.

(d) The Illinois Department may seek a revocation of any alternate payee, and all owners, officers, and individuals with management responsibility for such alternate payee shall be permanently prohibited from participating as an owner, an officer, or an individual with management responsibility with an alternate payee in the Illinois Medical Assistance Program, if after reasonable notice and opportunity for a hearing the Illinois Department finds that:

(1) the alternate payee is not complying with the Department's policy or rules and regulations, or with the terms and conditions prescribed by the Illinois Department in its alternate payee registration agreement; or

(2) the alternate payee has failed to keep or make available for inspection, audit, or copying, after receiving a written request from the Illinois Department, such records regarding payments claimed as an alternate payee; or

(3) the alternate payee has failed to furnish any information requested by the Illinois Department regarding payments claimed as an alternate payee; or

(4) the alternate payee has knowingly made, or caused to be made, any false statement or representation of a material fact in connection with the administration of the Illinois Medical Assistance Program; or

(5) the alternate payee, a person with management responsibility for an alternate payee, an officer or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate alternate payee, or a partner in a partnership which is an alternate payee:

(a) was previously terminated, suspended, or excluded from participation as a vendor in the Illinois Medical Assistance Program, or was previously revoked as an alternate payee in the Illinois Medical Assistance Program, or was terminated, suspended, or excluded from participation as a vendor in a medical assistance program in another state that is of the same kind as the program of medical assistance provided under Article V of this Code; or

(b) was a person with management responsibility for a vendor previously terminated, suspended, or excluded from participation as a vendor in the Illinois Medical Assistance Program, or was previously revoked as an alternate payee in the Illinois Medical Assistance Program, or was terminated, suspended, or excluded from participation as a vendor in a medical assistance program in another state that is of the same kind as the program of medical assistance provided under Article V of this Code, during the time of conduct which was the basis for that vendor's termination, suspension, or exclusion or alternate payee's revocation; or

(c) was an officer, or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate vendor previously terminated, suspended, or excluded from participation as a vendor in the Illinois Medical Assistance Program, or was previously revoked as an alternate payee in the Illinois Medical Assistance Program, or was terminated, suspended, or excluded from participation as a vendor in a medical assistance program in another state that is of the same kind as the program of medical assistance provided under Article V of this Code, during the time of conduct which was the basis for that vendor's termination, suspension, or exclusion; or

(d) was an owner of a sole proprietorship or partner in a partnership previously terminated, suspended, or excluded from participation as a vendor in the Illinois Medical Assistance Program, or was previously revoked as an alternate payee in the Illinois Medical Assistance Program, or was terminated, suspended, or excluded from participation as a vendor in a medical assistance program in another state that is of the same kind as the program of medical assistance provided under Article V of this Code, during the time of conduct which was the basis for that vendor's termination, suspension, or exclusion or alternate payee's revocation; or

(6) the alternate payee, a person with management responsibility for an alternate payee, an officer or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate alternate payee, or a partner in a partnership which is an alternate payee:

(a) has engaged in conduct prohibited by applicable federal or State law or regulation relating to the Illinois Medical Assistance Program; or

(b) was a person with management responsibility for a vendor or alternate payee at the time that the vendor or alternate payee engaged in practices prohibited by applicable federal or State law or regulation relating to the Illinois Medical Assistance Program; or

(c) was an officer, or person owning, either directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a vendor or alternate payee at the time such vendor or alternate payee engaged in practices prohibited by applicable federal or State law or regulation relating to the Illinois Medical Assistance Program; or

(d) was an owner of a sole proprietorship or partner in a partnership which was a vendor or alternate payee at the time such vendor or alternate payee engaged in practices prohibited by applicable federal or State law or regulation relating to the Illinois Medical Assistance Program; or

(7) the direct or indirect ownership of the vendor or alternate payee (including the ownership of a vendor or alternate payee that is a partner's interest in a vendor or alternate payee, or ownership of 5% or more of the shares of stock or other evidences of ownership in a corporate vendor or alternate payee) has been transferred by an individual who is terminated, suspended, or excluded or barred from participating as a vendor or is prohibited or revoked as an alternate payee to the individual's spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin, or relative by marriage.

(K) The Illinois Department of Healthcare and Family Services may withhold payments, in whole or in part, to a provider or alternate payee where there is credible evidence, received from State or federal law enforcement or federal oversight agencies or from the results of a preliminary Department audit, that the circumstances giving rise to the need for a withholding of payments may involve fraud or willful misrepresentation under the Illinois Medical Assistance program. The Department shall by rule define what constitutes "credible" evidence for purposes of this subsection. The Department may withhold payments without first notifying the provider or alternate payee of its intention to withhold such payments. A provider or alternate payee may request a reconsideration of payment withholding, and the Department must grant such a request. The Department shall state by rule a process and criteria by which a provider or alternate payee may request full or partial release of payments withheld under this subsection. This request may be made at any time after the Department first withholds such payments.

(a) The Illinois Department must send notice of its withholding of program payments within 5 days of taking such action. The notice must set forth the general allegations as to the nature of the withholding action, but need not disclose any specific information concerning its ongoing investigation. The notice must do all of the following:

(1) State that payments are being withheld in accordance with this subsection.

(2) State that the withholding is for a temporary period, as stated in paragraph (b) of this subsection, and cite the circumstances under which withholding will be terminated.

(3) Specify, when appropriate, which type or types of Medicaid claims withholding is effective.

(4) Inform the provider or alternate payee of the right to submit written evidence for reconsideration of the withholding by the Illinois Department.

(5) Inform the provider or alternate payee that a written request may be made to the Illinois Department for full or partial release of withheld payments and that such requests may be made at any time after the Department first withholds such payments.

(b) All withholding-of-payment actions under this subsection shall be temporary and shall not continue after any of the following:

(1) The Illinois Department or the prosecuting authorities determine that there is insufficient evidence of fraud or willful misrepresentation by the provider or alternate payee.

(2) Legal proceedings related to the provider's or alternate payee's alleged fraud, willful misrepresentation, violations of this Act, or violations of the Illinois Department's administrative rules are completed.

(3) The withholding of payments for a period of 3 years.

(c) The Illinois Department may adopt all rules necessary to implement this subsection (K).

(K-5) The Illinois Department may withhold payments, in whole or in part, to a provider or alternate payee upon initiation of an audit, quality of care review, investigation when there is a credible allegation of fraud, or the provider or alternate payee demonstrating a clear failure to cooperate with the Illinois Department such that the circumstances give rise to the need for a withholding of payments. As used in this subsection, "credible allegation" is defined to include an allegation from any source, including, but not limited to, fraud hotline complaints, claims data mining, patterns identified through provider audits, civil actions filed under the Illinois False Claims Act, and law enforcement investigations. An allegation is considered to be credible when it has indicia of reliability. The Illinois Department may withhold payments without first notifying the provider or alternate payee of its intention to withhold such payments. A provider or alternate payee may request a hearing or a reconsideration of payment withholding, and the Illinois Department must grant such a request. The Illinois Department shall state by rule a process and criteria by which a provider or alternate payee may request a hearing or a reconsideration for the full or partial release of payments withheld under this subsection. This request may be made at any time after the Illinois Department first withholds such payments.

(a) The Illinois Department must send notice of its withholding of program payments within 5 days of taking such action. The notice must set forth the general allegations as to the nature of the withholding action but need not disclose any specific information concerning its ongoing investigation. The notice must do all of the following:

(1) State that payments are being withheld in accordance with this subsection.

(2) State that the withholding is for a temporary period, as stated in paragraph (b) of this subsection, and cite the circumstances under which withholding will be terminated.

(3) Specify, when appropriate, which type or types of claims are withheld.

(4) Inform the provider or alternate payee of the right to request a hearing or a reconsideration of the withholding by the Illinois Department, including the ability to submit written evidence.

(5) Inform the provider or alternate payee that a written request may be made to the Illinois Department for a hearing or a reconsideration for the full or partial release of withheld payments and that such requests may be made at any time after the Illinois Department first withholds such payments.

(b) All withholding of payment actions under this subsection shall be temporary and shall not continue after any of the following:

(1) The Illinois Department determines that there is insufficient evidence of fraud, or the provider or alternate payee demonstrates clear cooperation with the Illinois Department, as determined by the Illinois Department, such that the circumstances do not give rise to the need for withholding of payments; or

(2) The withholding of payments has lasted for a period in excess of 3 years.

(c) The Illinois Department may adopt all rules necessary to implement this subsection (K-5).

(L) The Illinois Department shall establish a protocol to enable health care providers to disclose an actual or potential violation of this Section pursuant to a self-referral disclosure protocol, referred to in this subsection as "the protocol". The protocol shall include direction for health care providers on a specific person, official, or office to whom such disclosures shall be made. The Illinois Department shall post information on the protocol on the Illinois Department's public website. The Illinois Department may adopt rules necessary to implement this subsection (L). In addition to other factors that the Illinois Department finds appropriate, the Illinois Department may consider a health care provider's timely use or failure to use the protocol in considering the provider's failure to comply with this Code.

(M) Notwithstanding any other provision of this Code, the Illinois Department, at its discretion, may exempt an entity licensed under the Nursing Home Care Act, the ID/DD Community Care Act, or the MC/DD Act from the provisions of subsections (A-15), (B), and (C) of this Section if the licensed entity is in receivership.

305 ILCS 5/12-4.25

Amended by P.A. 102-0538,§ 735, eff. 8/20/2021.

Amended by P.A. 099-0180,§ 170, eff. 7/29/2015.

Amended by P.A. 098-0756,§ 540, eff. 7/16/2014.

Amended by P.A. 098-0550,§ 5, eff. 8/27/2013.

Amended by P.A. 098-0214,§ 80, eff. 8/9/2013.

Amended by P.A. 097-1150,§ 505, eff. 1/25/2013.

Amended by P.A. 097-0689,§ 75, eff. 6/14/2012.

Amended by P.A. 094-0975, § 5, eff. 6/30/2006.

Amended by P.A. 094-0265, § 5, eff. 1/1/2006.

P.A. 89-21, eff. 1-1-96; 90-725, eff. 8-7-98; 92-327, eff. 1-1-02; 92-651, eff. 7-11-02; 92-789, eff. 8-6-02.