Introduced By: Senators Parella, Flynn, Gibbs and Polisena
Date Introduced : February 10, 1998
Referred To: Committee on Senate Judiciary
It is enacted by the General Assembly as follows:
SECTION 1. Title 40 of the General Laws entitled "Human services" is hereby amended by adding thereto the following chapter:
{ADD 40-8.4-1. Short title. -- ADD} {ADDThis chapter shall be known and may be cited as the Medicaid Managed Health Care Fraud Control Act. ADD}
{ADD 40-8.4-2. Legislative findings. -- ADD} {ADD It is hereby found and declared as follows: ADD}
{ADD (A) Rhode Island has embarked upon a system of providing medical assistance through a managed care model. ADD}
( {ADD B) Other states which have adopted such plans have noted the inappropriateness of traditional false claims approaches to detection, investigation and prosecution of health care fraud. ADD}
( {ADD C) This change in the manner of providing medical assistance to the needy persons of this state from a predominately fee-for-service methodology to that of managed health care necessitates a new approach to the problem of health care fraud. ADD}
{ADD 40-8.4-3. Definitions. -- ADD} {ADD As used in this chapter: ADD}
{ADD (A) The term "benefit", means and includes money, property, commercial interests or anything else, the primary significance of which is economic gain. ADD}
{ADD (B) The terms "conviction" or "convicted", mean and include any instance where: ADD}
{ADD (1) a judgment of conviction has been entered against any person for a violation of this chapter or chapter 40-8.2, regardless of whether an appeal is pending or whether the judgment of conviction or other record relating to criminal conduct has been expunged; or ADD}
{ADD (2) there has been a finding of guilty for a violation of this chapter; or ADD}
{ADD (3) there has been a plea of guilty or nolo contendre for a violation of this chapter; or ADD}
{ADD (4) when the person has entered into a first offender program, deferred adjudication program, diversion program or other arrangement or program where a judgment of conviction has been withheld. ADD}
{ADD (C) The term "director", means and includes the director of the department of human services. ADD}
{ADD (D) The terms "false or fraudulent", mean and include, any statement or representation which is untrue or inaccurate in a material particular or which fails to disclose a material fact. ADD}
{ADD (E) The term "health care official", means and includes ADD}
{ADD (1) any administrator, officer, trustee, fiduciary, custodian, counsel, agent or employee of any health plan; ADD}
{ADD (2) any officer, counsel, agency, or employee of an organization that provides, proposes to, or contracts to provide services to any health plan; ADD}
{ADD (3) any official, employee, or agent of a state or federal agency having regulatory or administrative authority over any health plan. ADD}
{ADD (F) The terms "health plan" or "health care plan", means and include any state or federally funded or mandated health care plan or program and any private insurance carrier, health care cooperative or alliance, health maintenance organization, or any insurer, organization, entity, association, affiliation, or person which contracts for or provides goods or services that are reimbursed directly or indirectly by any state or federally funded or mandated health program. ADD}
{ADD (G) The terms "health care provider" or "provider", mean or include any person, who has applied to participate in, currently participates in, who has previously participated in, or who attempts or who has attempted to participate in a state or federally funded or mandated health care plan or program. ADD}
{ADD (H) The term "individual" means and includes a natural person. ADD}
{ADD (I) The term "kickback", means and includes a return in any form by an individual of a part of an expenditure made or to be made by a provider; ADD}
{ADD (1) To the same provider; or ADD}
{ADD (2) To an entity controlled by the provider; or ADD}
{ADD (3) To an entity which the provider intends to benefit whenever the expenditure is reimbursed, or reimbursable, or claimed by a provider as being reimbursable by the Rhode Island medicaid program and when the sum or value returned is not credited to the cost of the reimbursement under any state or federally funded or mandated health care plan or program. ADD}
{ADD (J) The term "organization", means and includes a person other than an individual. ADD}
{ADD (K) The term "person" means and includes any natural person and includes corporations, partnerships, associations, joint-stock companies, unions, trusts, pension funds, unincorporated organizations, limited liability companies, governments and political subdivisions thereof, and non-profit organizations. ADD}
{ADD (L) The term "recipient" means and includes an individual, either real or fictitious, on whose behalf any person claimed or received any payment or payments from a state or federally funded or mandated health care plan or program, whether or not such person was eligible for benefits under such plan or program. ADD}
{ADD (M) The term "records", means and includes all written documents and electronic, magnetic or optically retained or generated data, including, but not limited to medical records, X-rays, professional financial or business records relating to the care or treatment of any recipient; any item or service or accommodation rendered or claimed or for which payment was made by a state or federally funded or mandated health care plan or program, whether or not such person was eligible for benefits under such plan or program; any rates paid for such care, treatment, item, service or accommodation and any care, treatment, item, service or accommodation rendered or claimed or for which payment was made for nonparticipants in any state or federally funded or mandated health care plan or program so as to verify the rates or amount of care, treatment, items, services or accommodations rendered or claimed or for which payment was made by any state or federally funded or mandated health care plan or program, as well as any records that the state or federally funded or mandated health care plan or program may require a provider to maintain. ADD}
{ADD (N) The term "serious bodily injury", means and includes physical injury that: ADD}
{ADD (1) creates a substantial risk of death; or ADD}
{ADD (2)_ causes protracted loss or impairment of the function of any bodily part, member or organ; or ADD}
{ADD (3) causes serious permanent disfigurement. ADD}
{ADD (O) The term "state or federally funded or mandated health care plan or program" means any health care plan or program operating under an approved state plan under title XIX of the Social Security Act 42 U.S.C. Section 1396 et. seq., or under an allotment to the state under such title, or pursuant to a waiver of the provisions of such title or regulations promulgated thereunder. ADD}
{ADD (P) The terms "statement" or "representation" mean and include any electronic, electronic impulse, facsimile, magnetic, optical, oral, telephonic, or written communication that is utilized to identify any goods or service as being reimbursable by any state or federally funded or mandated health plan or program, or a communication that states income or expense and is or may be used to determine a rate of payment by a state or federally funded or mandated health care plan or program. ADD}
{ADD (Q) The term "unfair or deceptive marketing practices", means and includes knowingly: ADD}
{ADD (1) Making any false or misleading oral or written statements, visual descriptions, advertisements, or other representations of any kind which are offered or presented with the intent to mislead health care consumers with respect to any health care service, health plan or health care provider in connection with any state or federally funded or mandated health care plan or program; or ADD}
{ADD (2) Making representations that a health care plan or a health care provider offers any service, benefit, access to care, or choice which it does not have in connection with any state or federally funded or mandated health care plan or program; or ADD}
{ADD (3) Making representations that a health plan or health care provider has any status, certification, qualification, sponsorship, affiliation, or licensure which it does not have in connection with any state or federally funded or mandated health care plan or program; or ADD}
{ADD (4) Failing in connection with any state or federally funded or mandated health care plan or program to state a material fact if the failure deceives or tends to deceive; or ADD}
{ADD (5) Offering any kickback, bribe, reward, or benefit to any person as an inducement to select, or to refrain from selecting any health care service, health plan, or health care provider in connection with any state or federally funded or mandated health care plan or program, unless the benefit offered is medically necessary health care; or ADD}
{ADD (6) Use of health care consumer or other information which is or was obtained in connection with any state or federally funded or mandated health care plan or program which is confidential, privileged, or which cannot be disclosed to or obtained by the user without violating a state or federal confidentiality law, including: ADD}
{ADD (a) Medical records information; or ADD}
{ADD (b) Information which identifies the health care consumer or any member of his or her group as a recipient of health care benefits, items or services in any state or federally funded or mandated health care plan or program or, ADD}
{ADD (7) Use of any device or artifice in advertising a health plan or soliciting a health care consumer which misrepresents the solicitor's profession, status, affiliation, or mission in connection with any state or federally funded or mandated health care plan or program. ADD}
{ADD 40-8.4-4. Prohibited activities. -- ADD} {ADDIt shall be unlawful, ADD}
{ADD (A) For any provider to intentionally: ADD}
{ADD (1) appropriate to himself or to another a benefit worth five hundred dollars ($500) or more, by knowingly and willfully executing or conspiring to execute a scheme or artifice: ADD}
{ADD (a) to defraud any state or federally funded or mandated health program or health plan in connection with the delivery of, or payment for, health care benefits, items, or services; or ADD}
{ADD (2) to obtain by means of false or fraudulent pretense, representation, statement, or promise, money or any thing of value in connection with any state or federally funded or mandated health plan, in connection with the delivery of or payment for health care benefits, items, or services; or ADD}
{ADD (3) appropriate to himself or to another, a benefit worth less than five hundred dollars ($500), by knowingly and willfully executing or conspiring to execute a scheme or artifice; ADD} {ADD (a) to defraud any state or federally funded or mandated health program or health plan in connection with the delivery of, or payment for, health care benefits, items, or services; or ADD}
{ADD (b) to obtain by means of false or fraudulent pretense, representation, statement, or promise, money or anything of value in connection with any state or federally funded or mandated health care plan or program; or ADD}
{ADD (4) to directly or indirectly give, offer, or promise any thing of value to a health care official, or to offer or promise a health care official to give anything of value to another person, with intent: ADD}
{ADD (a) to influence or reward any acts or decisions of any health care official exercising any authority in any state or federally funded or mandated health plan; or ADD}
{ADD (b) to influence such official to commit or aid in the commission of or conspire to allow any fraud in a state or federally funded or mandated health plan; or ADD}
{ADD (c) to induce such an official to engage in any conduct in violation of the lawful duty of such official where such duty pertains to any state or federally funded or mandated health care plan or program; or ADD}
{ADD (5) to knowingly and willfully falsify, conceal or omit by any trick, scheme, artifice or device, a material fact, or make any false, fictitious or fraudulent statement or representation, or to make or use any false writing or document, knowing the same to contain any false, fictitious, or fraudulent statement or entry in any matter related to a state or federally funded or mandated health plan, regarding the provision of health care or related services; or ADD}
{ADD (6) to knowingly and willfully: ADD}
{ADD (a) Charge, a patient or anyone acting on behalf of a patient money or other consideration at a rate in excess of or in addition to any payment made by or on behalf of such person by a state or federally funded or mandated health care plan or program, excepting any copayment which may be authorized by the director in accordance with regulation; or ADD}
{ADD (b) Charge, solicit, accept, or receive, money or other consideration, including any gift or donation, in excess of or in addition to any payment made by or on behalf of such person by a state or federally funded or mandated health care plan or program, excepting any copayment which may be authorized by the director in accordance with regulation, as a precondition of the admission of a patient to a hospital, skilled nursing facility or intermediate care facility, or of the continued stay in a facility; or ADD}
{ADD (7) to knowingly and willfully engage in any unfair or deceptive marketing practices in connection with proposing, offering, selling, soliciting, or providing, any health care service or any health plan, in connection with any state or federally funded or mandated health care plan or program; or ADD}
{ADD (8) to charge or receive any payment, directly or indirectly, from any state or federally funded or mandated health care plan or program for any services rendered to participants in such health care plan or program subsequent to having actual or constructive knowledge of their then existing exclusion under the provisions of section 6(H) of this chapter or 42 U.S.C. 1320a-7 and prior to any reinstatement thereunder; or ADD}
{ADD (B) For any person being a health care official, to knowingly and willfully, directly or indirectly demand, solicit, receive, accept or agree to accept anything of value personally or for any other person with intent: ADD}
{ADD (i) to exercise his authority with respect to his or her official acts or decisions in any state or federally funded or mandated health plan in order to benefit such other person; or ADD}
{ADD (ii) to commit or aid in the commission of or conspire to allow any fraud in a state or federally funded or mandated health plan; or ADD}
{ADD (iii) to engage in any conduct in violation of the lawful duty of such official, where such duty pertains to any state or federally funded or mandated health care plan or program. ADD}
{ADD (C) For any person to knowingly and willfully pay, remuneration, including, but not limited to, any rebate, kickback, bribe, refund, commission, preference or other thing of value as an inducement for referring or for refraining from referring a patient, client, customer or service to or from any provider of health care services, equipment, or goods, any health care institution, any health care delivery system, or any health plan in connection with any state or federally funded or mandated health care plan or program unless such incentive is part of a financial incentive structure approved by an organization granting the incentive and where the decision to refer or not to refer is based upon appropriate medical standards and/or the medical necessity for such decision. ADD}
{ADD 40-8.4-5. Acts of officers, directors, representatives, or agents acting within the scope of their authority. -- ADD} {ADD(A) A corporation, association, firm, partnership, limited partnership, or limited liability company is liable for the acts of its officers, director, representatives, or agents acting within the scope of their authority Proof of the acts of any officer, director, representative, or agent shall be received as prima facie proof of the acts of the corporation, association, firm, partnership, limited partnership or limited liability company itself. ADD}
{ADD (B) When a corporation, association, firm, partnership, or limited partnership violates this chapter, the violation shall be deemed to be that of the individual directors, members, officers, managers, employees, or agents of the corporation, association, firm, partnership, limited partnership, or limited liability company who knowingly authorized, ordered, aided, abetted, or advised in the acts or omissions constituting in whole or in part the violation, whether the individuals acted on their own behalf and for their own benefit, or for the corporation, association, firm, partnership, limited partnership, or limited liability company and in their representative capacity. The individuals, in their capacity as individuals, are subject to the provisions of this chapter and may be joined, as additional parties defendant in the proceedings against the corporation, association, partnership, limited partnership, or limited liability company. ADD}
{ADD 40-8.4-6. Penalties. -- ADD} {ADD (A) Any person who commits a violation of subsections (A)(1), (A)(2), (A)(4), (A)(5), (A)(6), (B) or (C) of section 40-8.4-4 shall be guilty of a felony and upon conviction, be sentenced to a term of imprisonment not to exceed ten (10) years or fined not to exceed ten thousand dollars ($10,000) or both; ADD}
{ADD (B) Any person who commits a violation of subsection (A)(3) of section 40-8.4-4 shall be guilty of a misdemeanor and upon conviction, be sentenced to a term of imprisonment not to exceed one (1) year or fined not to exceed one thousand dollars ($1,000) or both; ADD}
{ADD (C) Any person who commits a violation of subsection (A)(7) of section 40-8.4-4 which constitutes unfair and deceptive marketing practices as that term is defined by subsections (3(Q)(1), (3)(Q)(2), (3)(Q)(3), (3)(Q)(4), (3)(Q)(5) or (3)(Q)(7) of section 40-8.4-3, shall be guilty of a felony and upon conviction be sentenced to a term of imprisonment not to exceed three (3) years or three thousand dollars ($3,000) or both; ADD}
{ADD (D) Any person who commits a violation of subsection (A)(7) of section 40-8.4-4, which constitutes unfair and deceptive marketing practices as that term is defined by subsection (3)(Q)(6) of section 40-8.4-3, shall be guilty of a misdemeanor and upon conviction be sentenced to a term of imprisonment not to exceed one (1) year or fined not to exceed one thousand dollars ($1,000) or both; ADD}
{ADD (E) Any person who commits a violation of this chapter which causes the death of, or serious bodily injury to, a participant in a health care plan, shall upon conviction be sentenced to imprisonment for life or any term of years, and a fine of up to fifty thousand dollars ($50,000), or both; ADD}
{ADD (F) Subsequent violations. Any person who has been previously convicted of a violation of this chapter or chapter 40-8.2, who is later convicted of a subsequent offense under this chapter shall: ADD}
{ADD (1) if the previous offense was a misdemeanor, be guilty of a felony and sentenced to a term not to exceed ten (10) years or fined not more than ten thousand dollars ($10,000) or both; or ADD}
{ADD (2) if the previous offense was a felony, be guilty of a felony and be sentenced to a term of imprisonment not to exceed twenty (20) years or fined not more than twenty thousand dollars ($20,000) or both. ADD}
{ADD (G) If the defendant found to have violated any felony violation of the provisions of this chapter is an organization, then it shall upon conviction be fined not to exceed two hundred fifty thousand dollars ($250,000) for each violation. ADD}
{ADD (H) Any person convicted under this chapter shall be excluded from participation in any health care plan or service program which is state or federally funded or mandated. Provided however, nothing herein shall be construed as excluding any individual from seeking, obtaining or retaining health care coverage for themselves or their family, if otherwise eligible, from any state or federally funded or mandated health care plan or program. ADD}
{ADD 40-8.4-7. Statute of limitations. -- ADD} {ADDThe statute of limitations for any criminal violation of the provisions of this chapter shall be ten (10) years, ADD}
{ADD 40-8.4-8. Civil remedy. -- ADD} {ADDAny person, including any state or federally funded or mandated health care plan or program or any state or federal entity responsible for the administration of such plan or program, injured by any violation of this chapter may recover through a civil action from the persons inflicting the injury three (3) times the amount of the injury. ADD}
{ADD 40-8.4-9. Damages for overcharges. -- ADD} {ADDWhen the cost of the services provided to the patient is being paid directly or indirectly by any state or federally funded or mandated health care program or plan, any provider who knows or should have known: ADD}
{ADD (A) that a recipient or anyone acting on behalf of a recipient has been charged by the provider, a payment, which in any form, is in excess of or in addition to any payment made by or on behalf of such person by a state or federally funded or mandated health care plan or program, excepting any copayment which may be authorized by the director in accordance with regulation; or ADD}
{ADD (B) that a patient or anyone acting on behalf of a patient has been charged, solicited, or who accepts, or receives, a payment, which in any form, is in excess of or in addition to any payment made by or on behalf of such person by a state or federally funded or mandated health care plan or program, excepting any copayment which may be authorized by the director in accordance with regulation, any gift, money, or donation as a precondition of the admission of a patient to a hospital, skilled nursing facility or intermediate care facility, or of the continued stay in a facility, shall be liable in a civil action to the patient or person acting on his or her behalf for an amount equal to three (3) times the amount of the charge. ADD}
{ADD 40-8.4-10. Civil actions brought by attorney general on behalf of persons injured by violations of chapter. -- ADD} {ADD(A) The attorney general may bring a civil action in superior court in the name of the state, as parens patriae on behalf of persons residing in this state, to secure monetary relief as provided in this section for injuries sustained by such persons by reason of any violation of this chapter. The court shall exclude from the amount of monetary relief awarded in an action any amount of monetary relief: ADD}
{ADD (1) Which duplicates amounts which have been awarded for the same injury; or ADD}
{ADD (2) Which is properly allocable to persons who have excluded their claims pursuant to subsection (C)(1) of this section. ADD}
{ADD (B) The court shall award the state as monetary relief threefold the total damage sustained as described in subsection (A) of this section and the costs of bringing suit, including reasonable attorney's fees. ADD}
{ADD (C) In any action brought under subsection (A) of this section, the attorney general shall, at such times, in such manner, and with such content as the court may direct, cause notice thereof to be given by publication. ADD}
{ADD (1) Any person on whose behalf an action is brought under subsection (A), may elect to exclude from adjudication the portion of the state claim for monetary relief attributable to him or her by filing notice of the election with the court within such time as specified in the notice given pursuant to this subsection. ADD}
{ADD (2) The final judgment in an action under subsection (A) shall be res judicata as to any claim under section 40-8.4-14 by any person on behalf of whom the action was brought and who fails to give notice within the period specified in the notice given pursuant to this subsection. ADD}
{ADD (D) An action under subsection (A) shall not be dismissed or compromised without the approval of the court, and notice of any proposed dismissal or compromise shall be given by publication at such times, in such manner, and with such content as the court may direct. ADD}
{ADD (E) In any action under subsection (A): ADD}
{ADD (1) The amount of the plaintiff's attorney's fees, if any, shall be determined by the court, and any attorney's fees awarded to the attorney general shall be deposited with the state as general revenues; and ADD}
{ADD (2) The court may, in its discretion, award a reasonable attorney's fee to a prevailing defendant upon a finding that the attorney general has acted in bad faith, vexatiously, wantonly, or for oppressive reasons. ADD}
{ADD (F) Monetary relief recovered in an action under this section shall: ADD}
{ADD (1) Be distributed in such manner as the court, in its discretion, may authorize; or ADD}
{ADD (2) Be deemed a civil penalty by the court and deposited with the state as general revenues, subject in either case to the requirement that any distribution procedure adopted afford each person a reasonable opportunity to secure his or her appropriate portion of the net monetary relief. ADD}
{ADD (G) In any action under this section the fact that a person or public body has not dealt directly with the defendant shall not bar or otherwise limit recovery, provided, however, the court shall exclude from the amount of monetary relief which duplicates amounts which have been awarded for the same injury. ADD}
{ADD 40-8.4-11. Injunctive relief. -- ADD} {ADD (A) The superior court of this state shall have jurisdiction to prevent and restrain violations of this chapter. In addition to granting prohibitory injunctive and other restraints for a period of time and upon terms and conditions necessary to deter a provider from, and insure against, the committing of future violations of this chapter, the court may grant injunctive relief reasonably necessary to dissipate the ill effects of the violation. The court may appropriate decrees upon consent and stipulation by the parties. The court may also issue restraining orders. Under no circumstances shall the state be required to post bond in any action hereunder. ADD}
{ADD (B) Attorney General -- Right to Injunctive Relief -- The attorney general may institute proceedings to prevent and restrain violations of this chapter as provided in subsection (A) of this section. ADD}
{ADD (C) Other persons -- Right to Injunctive Relief -- Any person, including the United States, may institute proceedings for injunctive relief, temporary or permanent, as provided in subsection (A) of this section against threatened loss or damage to his or her property or business by a violation of this chapter. A preliminary injunction may be issued upon a showing that the danger of irreparable loss or damage is immediate and, within the court's discretion, the execution of property bond against damages for an injunction improvidently granted. If the court issues a permanent injunction, the plaintiff shall be awarded reasonable attorney's fees, filing fees, and reasonable costs of the suit. Reasonable costs for the suit may include but shall not be limited to the expenses of discovery and document reproduction. ADD}
{ADD 40-8.4-12. Investigative demand. -- ADD} {ADD The attorney general or his or her designated assistant attorney general shall have the power to issue a subpoena or subpoena duces tecum: ADD}
{ADD (A) Demand. Whenever the attorney general has reasonable cause to believe that any person has knowledge or is in possession, custody, or control of any documentary material, pertinent to an investigation of a possible violation of this chapter, the attorney general may issue in writing and cause to be served upon the person an investigative demand by which he or she may: ADD}
{ADD (1) Compel the attendance of the person and require him or her to submit to examination and give testimony under oath; and/or ADD}
{ADD (2) Require the production of documentary material pertinent to the investigation for inspection or copying; and/or ADD}
{ADD (3) Require an answer to written interrogatories to be furnished under oath. The power to issue investigative demands shall not abate or terminate by reason of the bringing of any action or proceeding under this chapter. The attorney general may issue successive investigative demands to the same person in order to obtain additional information pertinent to an ongoing investigation. ADD}
{ADD Such civil investigative demands shall be filed in the superior court of the county in which the person served with the demand shall dwell, have his or her principal place of business, or the principal place of business of its registered corporate agent. ADD}
{ADD (B) Contents of Investigative Demand. Each investigative demand shall: ADD}
{ADD (1) State the section or sections of the chapter, the alleged violation of which is under investigation, and the general subject matter of this investigation; or ADD}
{ADD (2) Prescribe a reasonable return date not less than forty (40) days after service of the investigative demand, provided that an earlier date may be prescribed under compelling circumstances but in no event less than twenty (20) days; or ADD}
{ADD (3) Specify the time and place at which the person is to appear and give testimony, produce documentary material, and furnish answers to interrogatories or do any of a combination of the aforesaid; or ADD}
{ADD (4) Describe by class any documentary material required to be produced, so as to clearly indicate what is demanded; and ADD}
{ADD (5) Contain any interrogatories to which written answers under oath are required. ADD}
{ADD (C) Prohibition Against unreasonable Demand. No investigative demand shall: ADD}
{ADD (1) Contain any requirement which would be unreasonable or improper if contained in a subpoena issued by a court of this state; or ADD}
{ADD (2) Require the disclosure of any material or information which would be privileged, or which for any other reason would not be required to be disclosed by a subpoena issued by a court of this state, including, but not limited to, trade secrets or confidential scientific, technical, merchandising, production, management, or commercial information, to the extent that the same are protected pursuant to the Rhode Island rules of civil procedure. ADD}
{ADD (D) Offer of Documentary Evidence. Where the information requested upon oral examination or written interrogatory pursuant to an investigative demand may be derived or ascertained from the business records of the person upon whom the demand has been served or from an examination, audit, or inspection of the business records, or from a compilation, abstract, or summary based thereon, and the burden of deriving or ascertaining the answer is substantially the same for the attorney general as for the person from whom the information is requested, it is sufficient for that person to specify the records from which the answer may be derived or ascertained, and to afford the attorney general reasonable opportunity to examine, audit, or inspect the records and to make copies, compilations, abstracts, or summaries. ADD}
{ADD (E) Service of Investigative Demand. An investigative demand may be served by any means provided under the Rhode Island rules of civil procedure for service of a complaint in a civil action. ADD}
{ADD (F) Motion to Quash. Within twenty (20) days after the service of an investigative demand or at any time before the return date specified therein, whichever period is shorter, the person served may file in a state superior court and serve upon the attorney general a petition for an order of court modifying or setting aside the demand. The time allowed for compliance in whole or in part with the demand as deemed proper and ordered by the court, shall not run while the petition is pending before the court. The petition shall specify each ground upon which the petitioner relies in seeking relief, and may be based upon any failure of the demand to comply with the provisions of this chapter or upon any constitutional right or other legal right, privilege or qualified privilege of the party, including any claim that the demand seeks material or information which constitutes trade secrets or confidential scientific, technical, merchandising, production, management, or commercial information. If a qualified privilege is raised, the court may order the person to comply with the demand only upon a showing of particularized need and subject to an appropriate protective order. The provisions of this section shall be the sole and exclusive means for challenging the requirements of the demand. ADD}
{ADD (G) Those authorized to examine. The examinations of all persons pursuant to this section shall be conducted by the attorney general or his or her designee before an officer authorized to administer oaths in this state. The statement made shall be taken down stenographically or by a sound-recording device and shall be transcribed. ADD}
{ADD (H) Right of persons served with investigation demands. ADD}
{ADD (1) Any person required to attend and give testimony or to submit documentary material pursuant to this section shall be entitled to retain, or on payment of a lawfully prescribed cost, to procure a copy of any document he or she produces and of his or her own statements as transcribed. ADD}
{ADD (2) Any person compelled to appear under a demand for oral testimony pursuant to this section may be accompanied, represented, and advised by counsel. Counsel may advise the person in confidence, upon the request of the person. The person or counsel may object on the record to any question, in whole or in part, and shall briefly state for the record the reason for the objection. An objection may properly be made, received, and entered upon the record when it is claimed that the person is entitled to refuse to answer the question on grounds of any constitutional or other legal right or privilege, including the privilege against self-incrimination. The person shall not otherwise object to or refuse to answer any question, and shall not by him or herself or through counsel otherwise interrupt the oral examination. If the person refuses to answer any question, the attorney general may petition the superior court for an order compelling such person to answer the question. ADD}
{ADD (3) The information and materials supplied to the attorney general pursuant to an investigative demand shall not be permitted to become public or be disclosed by the attorney general or his or her employees beyond the extent necessary for enforcement purposes in the public interest. ADD}
{ADD (4) Upon the completion of a case brought under this chapter, the attorney general shall return any documents, answers, and transcripts, and all copies thereof, which have not passed into the control of the court through the introduction thereof, into the record, to the person who provided the documents, answers, or testimony. If no case in which the material may be used has been commenced within a reasonable time after completion of the examination or analysis of all documentary material, but in no event later than two (2) years after production thereof, the attorney general shall, upon written request of the person who produced the material, return all documents, answers, and transcripts, and all copies thereof, to the person who provided them. ADD}
{ADD (5) The attorney general shall have the authority, at any time, to modify or revoke any investigative demand and to stipulate to protective orders with respect to documents and information submitted in response to a demand. The protective orders shall include provisions appropriate to the full and adequate protection of confidential health care information pursuant to chapter 37.3 of title 5. ADD}
{ADD (I) Witness expenses. All persons served with an investigative demand, other than those persons whose conduct or practices are being investigated or any officer, director, or person in the employment of a person under investigation shall be paid the same fees and mileage as paid witnesses in the courts of this state. No person shall be excused from attending the inquiry pursuant to the mandate of an investigative demand or from giving testimony or from producing documentary material or from being required to answer questions on the ground of failure to tender or pay a witness fee or mileage, unless demand therefore is made at the time testimony is about to be taken or unless payment thereof is not thereupon made. ADD}
{ADD (J) Refusal of witness to testify or produce documents. Any person who shall neglect or refuse to attend and give testimony or to answer any lawful inquiry or to produce documentary material, if in his or her power to do so, in obedience to any investigative demand pursuant to this section, may be adjudged in civil contempt by the superior court until such time as he or she purges him or herself of contempt by testifying, producing documentary material, or presenting written answers as ordered. Any person who commits perjury or false swearing in response to an investigative demand pursuant to this section shall be punished pursuant to the provisions of chapter 33 of title 11. ADD}
{ADD (K) Duty to testify -- Immunity. ADD}
{ADD (1) If, in any investigation brought by the attorney general pursuant to this section, any individual shall refuse to attend or to give testimony or to produce documentary material or to answer a written interrogatory in obedience to an investigative demand or under order of court on the ground that the testimony or material required of him or her may tend to incriminate him or her, that person may be ordered to attend and to give testimony or to produce documentary material or to answer the written interrogatory, or to do an applicable combination of these pursuant to section 12-17-15. The order aforesaid shall be an order of court given after hearing in which the attorney general has established a need for the grant of immunity, as hereinafter provided. ADD}
{ADD (2) The attorney general may petition for an order as described in subsection (K)(1) above for any investigation pursuant to this chapter., The petition shall set forth the nature of the investigation and the need for the immunization of any witness. ADD}
{ADD (3) The witness shall not be prosecuted for or on account of any transaction or matter regarding which in accordance with the order, he or she gave answer or produced evidence and no testimony or other evidence compelled under the order or any information directly or indirectly derived from the testimony shall be used against the witness in any criminal proceeding. The grant of immunity shall not immunize the witness from civil liability arising from the transactions about which testimony is given, and he or she may nevertheless be presented or subjected to penalty or forfeiture for any perjury, false swearing, or contempt committed in answering or in failing to answer or in producing evidence or failing to do so in accordance with the order. The foregoing shall not prevent the attorney general from instituting other appropriate contempt proceedings against any person who violates any of the above provisions. ADD}
{ADD (L) Duty of public officials. It shall be the duty of all officials of this state and its public bodies, their deputies, assistants, clerks, subordinates, or employees, and all other persons to reorder and furnish to the attorney general when so requested, all information and assistant in their possession or within their power. ADD}
{ADD 40-8.4-13. Suspension of payments to a provider. -- ADD} {ADD The director may issue a suspension of payments order upon proof that: ADD}
{ADD (A) The provider does not meet certification requirements of the Rhode Island medical assistance program or federal law or regulation; or ADD}
{ADD (B) The Rhode Island medicaid program has been unable to collect (or make satisfactory arrangements for the collection of) amounts due on account of overpayments to any provider; or ADD}
{ADD (C) The Rhode Island medicaid program and/or the medicaid fraud control unit of the attorney general's office has been unable to obtain, from a provider, the data and information necessary to enable it to determine the existence or amount (if any) of the overpayments made to a provider; or ADD}
{ADD (D) The medicaid fund control unit of the attorney general's office has been denied reasonable access to information by a provider which pertains to a patient or resident of a long term residential care facility or to a former patient or resident of a long term residential care facility; or ADD}
{ADD (E) The Rhode Island medicaid program and/or the medicaid fraud control unit of the attorney general's office has been denied reasonable access to data and information by the provider for the purpose of conducting activities as described in section 1903(q) 42U.S.C. section 1396b(q) of the Social Security Act; or ADD}
{ADD (F) The Rhode Island medicaid program has been presented with reliable evidence that the provider has engaged in fraud or willful misrepresentation under any state or federally funded or mandated health care plan or program. ADD}
{ADD 40-8.4-14. Civil monetary penalty. -- ADD} {ADD Any person who, without the intent to defraud, submits or causes to be submitted any data, claims or information to any or on behalf of any state or federally funded or mandated health care plan, to any state or federal entity responsible for the administration or oversight or such plan or program and who knew or should have known that the data, claim or information was false, fraudulent or materially misleading shall be subject, in addition to any other penalties that may be prescribed by law, to a civil penalty of not more than two thousand dollars ($2,000) for each instance where the data, claim or information was false, fraudulent or misleading. In addition, he person may be assessed an amount equal to twice the value or damage to the health care plan or program, if applicable. ADD}
{ADD 40-8.4-15. Interest on overcharges. -- ADD} {ADDAny provider of benefits, items or services contracting with or providing services to any state or federally funded or mandated health care plan or program, pursuant to title XIX of the Social Security Act 42 U.S.C. Section 1396 et seq., who, without intent to defraud, obtains payments under this chapter in excess of the amount to which the provider is entitled, thereby becomes liable for payment of the amount of the excess with payment of interest allowable by law, under section 6-26-2, as was in effect on the date payment was made to the provider. The interest period will commence on the date upon which payment was made and will extend to the date upon which repayment is made. ADD}
{ADD 40-8.4-16. Statute of limitations -- Civil or administrative actions. -- ADD} {ADDThe statute of limitations for any civil violation of the provisions of this chapter shall be ten (10) years. ADD}
{ADD 40-8.4-17. Other civil remedies and criminal penalties. -- ADD} {ADDThe penalties and remedies under this statute are not exclusive and shall not preclude the use of any other civil remedy or the application of any other criminal penalty. ADD}
{ADD 40-8.4-18. Applicability. -- ADD} {ADDThe provisions of this chapter shall apply to providers who contract with or provide benefits, items or services to persons pursuant to any state or federally funded or mandated health care plan or program operated under Title XIX of the Social Security Act 42 U.S.C. section 1396 et seq., any waiver of the provisions of such act or any regulations promulgated thereunder, or pursuant to an allotment to a state under such title. ADD}
{ADD 40-8.4-19. Severability. -- ADD} {ADDIf any of the provisions of this chapter or the application thereof to any person or circumstance is held invalid or unconstitutional, the invalidity or unconstitutionality shall not effect other provisions or applications of this chapter which can be given effect without the invalid or unconstitutional provision or application, and to this end the provisions of this chapter are declared to be severable. ADD}
SECTION 2. This act shall take effect upon passage.
This act would criminalize certain conduct within the medicaid managed health care field. It would provide both criminal and civil sanction for violations.
This act would take effect upon passage.
