1997 Regular Session
To: Public Health and Welfare
By: Representative Moody
House Bill 687
AN ACT TO CREATE A NEW SECTION TO BE CODIFIED as SECTION 43-13-214, MISSISSIPPI CODE OF 1972, TO PRESCRIBE CRIMINAL PENALTIES APPLICABLE TO ANY MEDICAID MANAGED CARE PLAN; TO DEFINE AND PROHIBIT MEDICAID MANAGED CARE FRAUD; TO DEFINE AND PROHIBIT BRIBERY AND GRAFT IN CONNECTION WITH A MEDICAID MANAGED CARE PLAN; TO DEFINE AND PROHIBIT THE RECEIPT OF CONSIDERATION FOR REFERRING OR REFRAINING FROM REFERRING A PATIENT, CLIENT OR CUSTOMER IN CONNECTION WITH A MEDICAID MANAGED CARE PLAN; TO PROHIBIT FALSE STATEMENTS RELATING TO A MEDICAID MANAGED CARE PLAN; TO DEFINE AND PROHIBIT UNFAIR OR DECEPTIVE MARKETING PRACTICES IN CONNECTION WITH A MEDICAID MANAGED CARE PLAN; TO AMEND SECTION 43-13-215, MISSISSIPPI CODE OF 1972, TO PROVIDE ENHANCED CRIMINAL PENALTIES FOR CORPORATE DEFENDANTS RELATING TO MEDICAID MANAGED CARE PLANS; TO CREATE A NEW SECTION TO BE CODIFIED AS SECTION 43-13-216, MISSISSIPPI CODE OF 1972, TO DEFINE AND PROHIBIT FELONIOUS NEGLECT RELATING TO MEDICAID MANAGED CARE PLANS; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. The following shall be codified as Section 43-13-214, Mississippi Code of 1972:
43-13-214. (1) As used in this section:
(a) "Managed care plan" means a plan operated by a managed care entity as described in Section 83-41-403(c) for Medicaid recipients under contract with the Division of Medicaid in the Office of the Governor;
(b) "Covered representations and statements" include, but are not limited to, reports, claims, certifications, acknowledgments and ratifications of financial information, enrollment claims, demographic statistics, encounter data, health services available or rendered, and the qualifications of persons rendering health care and ancillary services;
(c) "Health care official" means:
(i) An administrator, officer, trustee, fiduciary, custodian, counsel, agent or employee of any managed care plan;
(ii) An officer, counsel, agency or employee of an organization that provides, proposes to, or contracts to provide services to any managed care plan; or
(iii) An official, employee or agent of a state or federal agency having regulatory or administrative authority over any managed care plan.
(2) A person shall not, with the intent to appropriate to himself or to another any benefit, knowingly execute, conspire to execute, or attempt to execute, a scheme or artifice:
(a) To defraud any managed care plan in connection with the delivery of, or payment for, health care benefits, items or services; or
(b) To obtain by means of false or fraudulent pretense, representation, statement or promise, money or anything of value in connection with the delivery of or payment for health care benefits, items or services which are in whole or in part paid for, reimbursed, subsidized by, or are a required benefit of, a managed care plan.
(3) A person shall not directly or indirectly give, offer or promise anything of value to a health care official, or offer or promise a health care official to give anything of value to another person, with intent:
(a) To influence or reward any acts or decisions of any health care official exercising any authority in any managed care plan; or
(b) To influence such official to commit or aid in the commission or conspire to allow any fraud in a managed care plan; or
(c) To induce such an official to engage in any conduct in violation of the lawful duty of such official.
(4) Any person who is a health care official shall not, directly or indirectly, demand, solicit, receive, accept or agree to accept anything of value personally or for any other person or entity, the giving of which would violate subsection (3) of this section.
(5) A person shall not knowingly pay, offer, deliver, receive, solicit or accept any remuneration, including, but not limited to, rebate, kickback, bribe, refund, commission, preference or other thing of value for referring or for refraining from referring a patient, client, customer or service in connection with a managed care plan to or from any (a) provider of health care services, equipment or goods; (b) health care institution; or (c) health care delivery system.
(6) A person shall not, in any matter related to any managed care plan, 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 make or use any false writing or document, knowing the same to contain any false, fictitious or fraudulent statement or entry in connection with the provision of health care or related services.
(7) A person shall not engage in any unfair or deceptive marketing practices in connection with proposing, offering, selling, soliciting or providing, any health care service in connection with any managed care plan. For purposes of this subsection (7), "unfair or deceptive marketing practices" include:
(a) Any false, misleading oral or written statement, visual description, advertisement, or other representation of any kind which has the capacity, tendency or effect of deceiving or misleading health care consumers with respect to any health care service or health care provider in connection with any managed care plan;
(b) Representation that a managed care plan or a managed care provider offers any service, benefit, access to care, or choice that it does not have;
(c) Representation that a managed care plan or managed care provider has any status, certification, qualification, sponsorship, affiliation or licensure that it does not have;
(d) Failure to state a material fact if the failure deceives or tends to deceive;
(e) Offering any kickback, bribe, reward or benefit to any person as an inducement to select, or to refrain from selecting any health care service or health care provider in connection with a managed care plan;
(f) Use of health care consumer or other information which is confidential, privileged, or which cannot be disclosed to or obtained by the user without violating a state or federal confidentiality law, including medical records information, or information which identifies the health care consumer or any member of his or her group as a recipient of any government sponsored or mandated welfare program;
(g) Use of any device or artifice in advertising a managed care plan or soliciting a health care consumer which misrepresents the solicitor's profession, status, affiliation or mission.
SECTION 2. Section 43-13-215, Mississippi Code of 1972, is amended as follows:
43-13-215. (1) A person who violates any provision of Sections 43-13-205 through 43-13-214 shall be guilty of a felony, and, upon conviction thereof, shall be punished by imprisonment for not more than five (5) years, or by a fine of not more than Fifty Thousand Dollars ($50,000.00), or both. Sentences imposed for convictions of separate offenses under this act may run consecutively.
(2) If the defendant found to have violated any provisions of Sections 43-13-205 through 43-13-214 is an organization, then it shall be subject to a fine of not more than Two Hundred Fifty Thousand Dollars ($250,000.00) for each felony. For purposes of this subsection, "organization" means a person other than an individual, and includes corporations, partnerships, associations, joint-stock companies, unions, trusts, pension funds, unincorporated organizations, governments and political subdivisions thereof, and nonprofit organizations.
SECTION 3. The following shall be codified as Section 43-13-216, Mississippi Code of 1972:
43-13-216. Anyone causing death or serious bodily injury to a person who is enrolled in a managed care plan as defined in Section 43-13-214 as the result of executing a scheme or artifice described in Section 43-13-214 with gross negligence or reckless disregard of human life shall be guilty of felonious neglect, and upon conviction thereof, shall be punished by imprisonment in the State Penitentiary for a term of years not to exceed twenty (20) years.
SECTION 4. This act shall take effect and be in force from and after July 1, 1997.