S.P. 444 - L.D. 1356
An Act To Improve Complaint Resolution and Hearing Procedures in the Department of Human Services
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 22 MRSA §13, sub-§6 is enacted to read:
6. Limitation on actions to recover overpayments. The department may impose a sanction or withhold payment from a MaineCare provider in order to recover or impose penalties for an overpayment for services rendered or goods delivered under the MaineCare program as provided in this subsection.
A. The department may impose a sanction or withhold payment when the department has ob-tained an order from Superior Court allowing interim sanctions upon showing a substantial likelihood that overpayment or fraud has occurred or that substantial harm to the department will result from further delay or when the department has taken final agency action and the provider has waived or exhausted its right to judicial review.
B. Notwithstanding paragraph A, the department may terminate or suspend the participation of a provider in the MaineCare program in lieu of recoupment pending final determination regarding an overpayment as long as 30 days' notice is given.
Sec. 2. 22 MRSA §42, sub-§7, as enacted by PL 2001, c. 666, Pt. C, §1, is amended to read:
7. Appeal process. The department shall amend the rules governing appeals of informal review decisions of
Medicaid MaineCare payment and cost report audit and review issues filed by MaineCare providers of nursing facility services and medical and remedial private nonmedical institution services of goods and services or initiated by the department and any other informal review decisions that seek to impose repayment, recovery or recoupment obligations or sanctions or fines on providers as provided in this subsection.
A. The department shall give to the provider involved in an informal review decision written notice of the appeal process and the time period for filing a notice of appeal.
B. The department shall contract with a person or persons who are not employees of the department for independent, impartial hearing officer services.
C. Compensation under
the any contract into which the department enters for hearing officer services may reflect the number of appeals on which recommendations are made by the hearing officer and may not reflect the substance of the recommendations made by the hearing officer.
D. The hearing officer shall conduct a hearing de novo on issues raised in the notice of appeal filed by the provider and shall in a timely manner render a written recommendation based on the record and in accordance with applicable state and federal law, rule and regulation. The hearing officer shall provide a copy of the recommendation to the department and to the provider along with notice of the opportunity to submit written comments to the commissioner.
E. The recommendation of the hearing officer must be forwarded to the commissioner for a final decision, based on the record, which must include any written comment submitted in a timely manner by the provider and the department. The commissioner may adopt, adopt with modification or reject the recommendation of the hearing officer. The commissioner shall issue a final decision in writing, which must include the reasons for any departure from the recommendation of the hearing officer and notice of the process for appeal pursuant to Title 5, chapter 375, subchapter
VII 7. If the commissioner deviates from a prior decision cited in the course of a proceeding, the final decision must include an explanation of the reason that the prior decision was not followed.
F. By July 1, 2004 the department shall make available on its publicly accessible site on the Internet the decisions in all MaineCare provider appeals beginning January 1, 2004, including the recommendations of the hearing officer and the decision of the commissioner.
(1) The site must include a search feature allowing users to obtain information on specific issues of interest.
(2) The site must protect information that is personal or confidential.
G. In lieu of the appeal procedure provided in this subsection, the parties may choose arbitration by a qualified arbitrator or panel of arbitrators as provided in this paragraph. By January 1, 2004, the department shall adopt rules to implement this paragraph that are consistent with federal law and regulation. Rules adopted pursuant to this paragraph are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
(1) The arbitrator or panel of arbitrators must be selected and compensated as agreed by the parties.
(2) Arbitration under this paragraph is available only when the amount in controversy is $10,000 or less and the subject matter in controversy is assessments, recovery or recoupment orders, sanctions or administrative fines.
(3) A provider choosing arbitration under this paragraph may waive any right of appeal.
H. In an administrative appeal of an informal review decision under this subsection, the department bears the burden of proving a violation of law or rule by a preponderance of the evidence. If the department proves that records of goods or services are defective, the department may impose the sanction of total recoupment only when the provider has failed to demonstrate by a preponderance of the evidence that the disputed goods or services were actually provided to eligible MaineCare members.
The department shall provide funding for contractual services under this subsection from within existing resources.
Sec. 3. 22 MRSA §48 is enacted to read:
§48. Provider relations
Department personnel assigned to MaineCare provider relations shall assist MaineCare providers in addressing and resolving in a cost-effective and expeditious manner any disagreements between the department and providers or groups of providers. Provider relations personnel shall receive and investigate complaints and concerns from providers regarding the MaineCare program and the MaineCare reimbursement prior to informal review or administrative hearing. In performing their duties under this subsection, the provider relations personnel must have access to the Director of the Bureau of Medical Services. The department shall implement the provisions of this section within existing resources.
Sec. 4. 22 MRSA §1714-A, sub-§2, as amended by PL 2001, c. 596, Pt. B, §4 and affected by §25, is further amended to read:
2. Establishment of debt. A debt is established by the department when it notifies a provider of debt that the provider owes the department pursuant to a
final reconciliation decision and order that constitutes final agency action. A debt is collectible by the department 31 days after exhaustion of all administrative appeals and any judicial review available under Title 5, chapter 375.
Sec. 5. 22 MRSA §1714-A, sub-§5, as enacted by PL 1991, c. 568, §4, is amended to read:
5. Department may offset. The department may offset against current reimbursement owed to a provider or any entity related by ownership or control to that provider any debt it is owed by that provider after the debt becomes collectible. The department shall adopt rules that implement this subsection and define the ownership or control relationships that are subject to an offset under this subsection. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
Sec. 6. Complaint resolution and informal hearing process recommendations. By January 5, 2004, the Department of Human Services and the Department of Behavioral and Developmental Services, in conjunction with their duties with regard to merger of the 2 departments under Public Law 2003, chapter 20, Part K, section 18, shall report to the Joint Standing Committee on Health and Human Services recommendations to improve the MaineCare complaint resolution and informal hearing process that ensure that MaineCare providers receive fair and impartial complaint resolution procedures and informal hearings.
Effective September 13, 2003, unless otherwise indicated.
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