Medi-Cal: providers: fraud.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law requires an applicant or provider, as defined, to submit a complete application package for enrollment, continuing enrollment, or enrollment at a new location or a change in location, and requires the application form for enrollment, the provider agreement, and all attachments or changes to be signed under penalty of perjury. Existing law authorizes the department, upon receipt of reliable evidence, as described, of fraud or willful misrepresentation by a provider, or upon the commencement of a specified suspension of a provider, to, among other things, withhold payment for any goods, services, supplies, or merchandise, or any portion thereof. Existing law prohibits the department from enrolling any applicant that has been convicted of any felony or misdemeanor involving fraud or abuse in any government program. This bill would revise these provisions to require, upon receipt of a credible allegation of fraud for which an investigation is pending under the Medi-Cal program against a provider, or upon the commencement of the specified suspension of a provider, that the provider be temporarily placed under payment suspension, unless it is determined there is good cause, as defined, not to suspend the payments or to suspend them only in part. This bill would prohibit the department from enrolling a provider in, or would require the department to terminate the provider from, the Medi-Cal program, if it is discovered that the provider has been terminated under Medicare or under the Medicaid Program or Children's Health Insurance Program in any other state, and would provide that a temporary suspension may be lifted if a resolution of an investigation for fraud or abuse occurs, as defined. This bill would require, commencing as specified, the department to conduct a criminal background check and require submission of a set of fingerprints when the department designates a provider as a "high" categorical risk, as specified. This bill would require the department, commencing as specified and with some exceptions, to collect an application fee for enrollment, including enrollment at a new location or a change in location in the amount calculated by the federal Centers for Medicare and Medicaid Services. This bill would authorize the department to establish a temporary moratorium on enrollment of providers under specified circumstances. This bill would make other related and conforming changes. This bill would require, on a quarterly basis, that the Department of Justice, and any other law enforcement agency that has accepted referrals for investigation from the department, report to the department a listing of each referral, stating whether the referral continues to be under investigation and whether it involves a credible allegation of fraud. To the extent that this bill increases the duties of local law enforcement agencies, this bill would create a state-mandated local program. This bill would authorize the department, effective January 1, 2012, to enter into contracts with one or more eligible Medicaid Recovery Audit Contractors pursuant to specified federal law. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.