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False Claims (Grove) |
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- When an individual knowingly submits a fraudulent claim with the intent to defraud the government, that individual is liable for payment.
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- Definition of “knowing” or “knowingly” means the individual had actual knowledge that the statement or claim was false.
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National Provider Identification Number (NPI) – HB 876 (Cabell)
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- In 2019, then PA Attorney General Josh Shapiro supported the grand jury recommendation that DHS should require anyone providing services under Medicaid in PA shall be identified with either a NPI or State Provider Identification (SPI). |
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- Provider identification will ensure proper documentation and accountability for processing payment and claims. |
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DO NOT PAY Initiative – HB 44 (Owlett) |
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- Establish a state database of organizations, individuals and entities which are not eligible to receive funds from a commonwealth agency. |
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Improper Payments – HB 971 (Gaydos) |
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- Defined as an overpayment/underpayment or a payment for an ineligible service or a payment to someone who was ineligible to receive it.
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- Legislation requires agencies to review programs and expenditures and assess whether they are susceptible to an improper payment. |
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Provider Preventable Conditions (PPC) – HB 1105 (Scialabba) |
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- PPCs-Health care acquired conditions in in-patient settings- which results in higher costs (e.g., Pressure sores/ hip fractures) OR an invasive or surgical procedure performed on the wrong person or body part.
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- Any Medicaid service provider who fails to keep proper documentation to ensure PPCs do not occur will face substantial fines.
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- The fines will serve as a deterrent to providers to ensure that providers do not file claims for egregious mistakes on part of the provider. |
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Stopping Medicaid and False Claims (Kauffman) |
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- Triple damages and enhance civil penalties to those who knowingly pursue false or fraudulent Medicaid claims. |
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Cross Checks for Medical Assistance – HB 421 (Hamm) |
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- Verity eligibility by cross checking applicants for – lottery winnings, death records, employment and income, residency, and incarceration. |
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Work and Volunteer Requirements for Medicaid Eligibility (Scialabba) |
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- Requires able-bodied adults between the ages of 18-65 to work or volunteer a set amount of hours for Medicaid eligibility. |
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Out of State EBT Card Management Program (Warner) |
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- Requires DHS to create an Electronic Benefits Transfer Card Management Program to develop electronic controls, oversight mechanisms, and follow-up procedures to detect and track fraudulent uses. |
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Securing EBT Card Transactions with Authorized Users (Warner) |
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- Requires authorized users for EBT cards to sign the same rights and responsibilities agreements as those who are eligible for benefits, holding all recipients and authorized users to the same standards of use |
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Grand Jury Recommendations for MA Fraud (Kutz) |
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- Increases the penalties for making a false claim against the commonwealth’s Medical Assistance to: |
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- A felony of the second degree if the fraudulent claim is $100,000 or more. |
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- A felony of the third degree if the fraudulent claim is between $2,000 and $100,000.
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- A misdemeanor of the third degree if the fraudulent claim is less than $2,000. |
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Medical Integrity Waivers – HB 331 (Stambaugh) |
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- Requires DHS to annually apply for the following waivers: |
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- Fraud lockout – prohibit re-enrollment and deny eligibility for up to six months for non-disabled, non-pregnant adults between the ages of 19-64 years who fail to report changes in circumstances impacting their eligibility.
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- Redetermination waiver – enable DHS to redetermine eligibility every six months instead of annually.
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- Suspension of automatic renewal and prepopulated forms to ensure redeterminations occur using correct information. |
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Commonwealth Grant Accountability and Transparency Act (Marcell) |
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- Requires the establishment of uniform administrative requirements, cost principles, and audit requirements for state and federal pass-through awards to non-federal entities. |
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Federal Funds Oversight (Grove)
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- Require the Office of the Budget and state agencies to complete a report prior to accepting federal funding. |
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- Requires state agencies to create a transparency portal for federal dollars.
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- Requires the IFO to review current federal funding to ascertain the costs of federal strings attached to accepting the funds. |