08 LC 28
3885
Senate
Bill 401
By:
Senators Staton of the 18th, Carter of the 13th, Chance of the 16th, Rogers of
the 21st, Grant of the 25th and others
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Article 7 of Chapter 4 of Title 49 of the Official Code of Georgia
Annotated, relating to medical assistance generally, so as to provide that
agency interpretations of rules and regulations and policies shall prevail in
the investigation of improper payment of claims by health care providers; to
provide for a method of review of such interpretations; to provide for certain
notices of investigations and possible prosecutions; to provide an exception; to
provide for a review of denied claims for the period under investigation; to
provide for advisory opinions under certain circumstances; to provide for
related matters; to repeal conflicting laws; and for other
purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Article
7 of Chapter 4 of Title 49 of the Official Code of Georgia Annotated, relating
to medical assistance generally, is amended by adding new Code sections to read
as follows:
"49-4-146.4.
(a)(1)
In any investigation, prosecution, or action brought under this article, the
interpretations of the rules and regulations and policies concerning the
payments of claims by the agency that is responsible for promulgating the rules
and regulations or policies shall prevail and be given effect. No
interpretation of the rules and regulations or policies concerning the payments
of claims that differs from the interpretation by the agency that is responsible
for promulgating the rules and regulations or policies shall be used as a basis
for an investigation, prosecution, or other action under this
article.
(2)
During the course of an investigation of a health care provider under Code
Section 49-4-146.3, the health care provider shall have the right to petition
the agency responsible for paying the claims in dispute or under investigation
for a hearing as to whether the claims were paid correctly by the agency. Such
hearing shall be conducted under the provisions of Chapter 13 of Title 50, the
'Georgia Administrative Procedure Act.' If, after the hearing, the agency finds
that the claims were properly paid or were correctly submitted under the
interpretations of the rules and regulations or policies in effect at the time
that the claims were submitted for payment, such claims shall no longer be the
basis of any further investigation, prosecution, or other action under this
article. Appeals from the decision of the agency may be taken in accordance
with Chapter 13 of Title 50.
(b)
In any investigation or possible prosecution under this article, the health care
provider shall be notified in writing prior to any other member of the public
being notified of such investigation or possible prosecution that an
investigation or possible prosecution has been opened against the health care
provider, and such notification shall provide a full description of the matters
under investigation or subject to possible prosecution. This notice may be
waived upon application to a judge of superior court of the county of the
health care provider´s main business location upon a good faith showing
that there would be a substantial likelihood that the providing of such notice
would result in the destruction of evidence, tampering with evidence or
witnesses, or the substantial impairment of the investigation or possible
prosecution.
(c)
If a person initiates an investigation of the alleged improper payment of claims
under this article, such person shall specify the time frame covered by the
investigation in the initial notice to the health care provider under subsection
(b) of this Code section. Notwithstanding any provision of law to the contrary,
the health care provider shall be able to have any claims denied during such
time period reviewed by the agency that denied such claims and, if such claims
are found to have been improperly denied, such claims shall be considered timely
filed and shall be paid by the agency.
49-4-146.5
(a)
Beginning on January 1, 2009, any agency that is responsible for implementing
this article or that promulgates rules and regulations or policies to implement
this article shall issue written advisory opinions as provided in this Code
section.
(b)
The agency shall issue advisory opinions as to the following
matters:
(1)
Clarification of sections of the agency´s policy manual for which
clarification is requested by a health care provider; and
(2)
Clarification of any processes or procedures required for the filing or managing
of claims for which clarification is requested by a health care
provider.
(c)
Each advisory opinion issued by an agency shall be binding as to the agency and
the party or parties requesting the opinion. The failure of a party to seek an
advisory opinion shall not be introduced into evidence to prove that the party
intended to violate any provision of this article.
(d)
Not later than January 1, 2009, each agency subject to the advisory opinion
requirements of this Code section shall issue rules and regulations to carry out
this Code section. Such regulations shall provide for:
(1)
The procedure to be followed by a party applying for an advisory
opinion;
(2)
The procedure to be followed by the agency in responding to a request for an
advisory opinion;
(3)
The interval in which the agency shall respond;
(4)
The reasonable fee to be charged to the party requesting an advisory opinion;
and
(5)
The manner in which advisory opinions shall be made available to the
public.
If
an agency does not respond to a request for an advisory opinion in a timely
manner, the health care provider requesting such opinion shall not be held
liable in any investigation relating to the subject matter of the requested
advisory opinion.
(e)
Under the rules and regulations promulgated pursuant to subsection (d) of this
Code section:
(1)
The agency shall be required to issue an advisory opinion to a party requesting
such advisory opinion not later than 60 days after the request is received;
and
(2)
The fee charged to the party requesting an advisory opinion shall be equal to
the costs incurred by the agency in responding to the
request."
SECTION
2.
All
laws and parts of laws in conflict with this Act are repealed.