2018 Regular Session ENROLLED
SENATE BILL NO. 507
BY SENATOR MILLS
1 AN ACT
2 To enact R.S. 46:460.72 and 460.73, relative to Medicaid managed care organizations; to
3 provide for provider notice requirements; to provide for plan payment accountability;
4 to provide for payment to providers; to provide for obligations by the managed care
5 organizations; to provide for prohibited claims for purposes of rate setting; to
6 provide for authority of the attorney general; to provide for deposits into the Medical
7 Assistance Programs Fraud Detection Fund; and to provide for related matters.
8 Be it enacted by the Legislature of Louisiana:
9 Section 1. R.S. 46:460.72 and 460.73 are hereby enacted to read as follows:
10 §460.72. Medicaid managed care organization provider notice
11 A. Each Medicaid managed care organization shall comply with the
12 following notice provisions regarding contracted provider status and ability to
13 begin providing services and submitting claims for reimbursement:
14 (1) Any Medicaid managed care organization that contracts with or
15 enrolls a provider into its provider network shall furnish written notice to the
16 provider that informs the provider of the effective date of the contract and
17 enrollment.
18 (2) Unless otherwise authorized by law, a provider shall not submit
19 Medicaid reimbursement claims for any services provided prior to the effective
20 date indicated in the written notice.
21 (3) The Medicaid managed care organization shall send the written
22 notice required in this Subsection to the last mailing address and last email
23 address submitted by the provider.
24 B. Each Medicaid managed care organization shall comply with the
25 following notice provisions regarding contracted provider re-credentialing:
26 (1) Each Medicaid managed care organization shall provide a minimum
27 of three written notices to a contracted provider with information regarding the
ACT No. 489
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1 re-credentialing process, including requirements and deadlines for compliance.
2 The first notice shall be issued by the Medicaid managed care organization no
3 later than six months prior to the expiration of the provider's current
4 credentialing. The notice shall include the effective date of termination if the
5 provider fails to meet the requirements and deadlines of the re-credentialing
6 process.
7 (2) The Medicaid managed care organization shall send the written
8 notices required in this Subsection to the last mailing address and last email
9 address submitted by the provider.
10 (3) If the provider fails to timely submit all required documents and meet
11 all re-credentialing requirements, the Medicaid managed care organization
12 shall send a termination notice to the provider with an effective date of
13 termination to be fifteen days after the date of the notice. The Medicaid
14 managed care association shall send the termination notice via certified mail to
15 the provider's last mailing address as submitted by the provider. The Medicaid
16 managed care organization shall be responsible for paying any claims for
17 services delivered prior to the termination date specified in the notice.
18 C. If a Medicaid managed care organization terminates a provider and
19 removes a provider from its provider network for reasons other than failure to
20 comply with the re-credentialing process set forth in Subsection C of this
21 Section, the Medicaid managed care organization shall send written notice of
22 the termination via certified mail to the last known mailing address submitted
23 by the provider. The termination notice shall include the effective date of the
24 termination. The termination date shall be fifteen days from the date of the
25 notice if the termination is pursuant to R.S. 46:460.73(A). The termination shall
26 be immediate if the termination is pursuant to R.S. 46:460.73(B) or due to the
27 loss of required license.
28 D. A provider shall give written notice of any change in licensure or
29 accreditation status to each Medicaid managed care organization with which it
30 is contracted or enrolled in a provider network. The provider shall furnish such
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1 written notice to the Medicaid managed care organization within two business
2 days of the provider's knowledge of the change.
3 §460.73. Medicaid managed care organization payment accountability
4 A.(1) Each Medicaid managed care organization shall be responsible for
5 ensuring that any provider it contracts with or enrolls into its network has
6 attained and satisfies all Medicaid provider enrollment, credentialing, and
7 accreditation requirements and all other applicable state or federal
8 requirements in order to receive reimbursement for providing services to
9 Medicaid recipients. Any Medicaid managed care organization that contracts
10 with or enrolls a provider into its provider network and fails to ensure proper
11 compliance with Medicaid provider enrollment, credentialing, or accreditation
12 requirements shall be liable for reimbursement to the provider for any services
13 rendered to Medicaid recipients until such time as the deficiency is identified by
14 the Medicaid managed care organization and notice is issued to the provider
15 pursuant to R.S. 46:460.72. Reimbursement for any services provided during
16 the fifteen-day remedy period after notice of the deficiency was identified by the
17 Medicaid managed care organization, or during a longer period if allowed by
18 the department, shall be withheld if the provider elects to continue providing
19 services while the deficiency is under review. If the deficiency is remedied, the
20 Medicaid managed care organization shall remit payment to the provider. If the
21 deficiency is not remedied, nothing in this Subsection shall be construed to
22 preclude the managed care organization from recouping funds from the
23 provider for any period in which the provider was not properly enrolled,
24 credentialed, or accredited.
25 (2) If a provider cannot remedy the deficiency within fifteen days and
26 believes that the deficiency was caused by good faith reliance on misinformation
27 by the managed care organization and the provider asserts that he acted
28 without fault or fraudulent intent he may seek review of the matter by the
29 department if he believes there is no deficiency or that because of his reliance
30 on misinformation from the Medicaid managed care organization, he cannot
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1 remedy the deficiency within fifteen days, but that an exception should be made
2 to allow him reasonable time to come into compliance so as to not disrupt
3 patient care. The provider shall prove absence of fault or fraudulent intent by
4 producing guidance, applications, or other written communication from the
5 managed care organization that bears incorrect information, including whether
6 the misinformation or guidance was contradictory to applicable Medicaid
7 manuals, rules, or policies.
8 (3) The department shall review all materials and information submitted
9 by the provider and shall review any information necessary that is in the
10 custody of the Medicaid managed care organization to render a written decision
11 within thirty days of the date of receipt for review submitted by the provider.
12 If the department's decision is in favor of the provider, a reasonable time shall
13 be afforded to the provider to remedy the deficiency caused by the
14 misinformation of the Medicaid managed care organization. During this time,
15 the provider shall be allowed to provide services and submit claims for
16 reimbursement. The written decision issued pursuant to this Paragraph shall
17 be sent to the provider and the Medicaid managed care organization by
18 certified mail.
19 (4) In addition to the managed care organization being responsible for
20 payment to the provider, the department may impose penalties on the managed
21 care organization in accordance with contract provisions or rules and
22 regulations promulgated pursuant to the Administrative Procedure Act.
23 (5) If the department's decision is not in favor of the provider, the
24 provider's contract shall be terminated immediately pursuant to the notice
25 provided for in R.S. 46:460.72(C).
26 (6) If the department's decision is that the provider acted with fault or
27 fraudulent intent, the provisions of Subsection B of this Section shall apply.
28 (7) The written decision by the department is the final administrative
29 decision and no appeal or judicial review shall lie from this final administrative
30 decision.
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1 B.(1) Each Medicaid managed care organization shall be responsible for
2 mitigating fraud, waste, and abuse of the funds it receives in the form of per-
3 member per-month rates for the provision of services to its plan enrollees. Any
4 Medicaid managed care organization that contracts with or enrolls a provider
5 into the provider network and fails to mitigate fraud, waste, and abuse by a
6 provider who acted with fault or fraudulent intent in securing a contract or
7 submitting claims shall void all claims and previous encounters for the provider.
8 (2) Failure to execute the provisions of their responsibility to mitigate
9 fraud, waste, and abuse shall not be considered a risk of the Medicaid managed
10 care organization for purposes of calculating per-member per-month rates. All
11 claims associated with fraud, waste, and abuse shall be voided. Voided claims
12 shall not be used for purposes of rate setting or by the Medicaid managed care
13 organization to seek an increase in rates or payments.
14 (3) The provisions of this Subsection do not preclude the Medicaid
15 managed care organization from recouping and retaining improper payments
16 and overpayments to a provider.
17 (4) In addition to the managed care organization being responsible for
18 voiding all claims and encounters associated with fraud, waste, and abuse for
19 any payments made to a provider, the department may impose penalties on the
20 managed care organization in accordance with contract provisions or rules and
21 regulations promulgated pursuant to the Administrative Procedure Act.
22 (5) The Medicaid managed care organization shall be liable to the
23 department for any other costs, expenses, claims, or reimbursement incurred
24 or expended by the department due to the provider's fault or fraudulent intent.
25 C. Each Medicaid managed care organization shall report every instance
26 of suspected fraud, waste, or abuse to the department and the attorney general.
27 In addition to the sanction and enforcement authority of the department
28 pursuant to a properly executed contract or properly promulgated rule, the
29 attorney general shall have the authority to investigate, enforce, impose
30 sanctions upon, and seek recoveries from any Medicaid managed care
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1 organization pursuant to the provisions of this Section and the Medical
2 Assistance Programs Integrity Law, R.S. 46:437.1 et seq. Recoupments shall be
3 returned to the department. All other sanctions, penalties, civil monetary
4 penalties, and additional recoveries or costs of investigations obtained by the
5 attorney general shall be deposited into the Medical Assistance Programs Fraud
6 Detection Fund, as established in R.S. 46:440.1. No Medicaid managed care
7 organization or any officer, director, employee, representative, or agent thereof
8 shall have any liability to the provider or any other person for reporting any
9 suspected fraud to the department or to the attorney general as required by this
10 Section.
11 D. Nothing in this Section shall be construed to prevent the department
12 or the attorney general from enforcing and imposing penalties otherwise
13 provided for in law or regulation.
14 E. The department shall promulgate rules and regulations necessary to
15 implement the provisions of this Section in accordance with the Administrative
16 Procedure Act.
17 F. Nothing in this Section shall be construed to supersede or conflict with
18 the provisions of R.S. 46:460.62.
19 G. The provisions of this Section shall be subject to approval by the
20 Centers for Medicare and Medicaid Services.
PRESIDENT OF THE SENATE
SPEAKER OF THE HOUSE OF REPRESENTATIVES
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED:
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