4123-6-02.51 Provider access to the HPP - denial of provider, entity or MCO certification based on criminal conviction or civil action.

 

 

 

Rule Summary and Fiscal Analysis (Part A)

 

Bureau of Workers' Compensation

Agency Name

 

Tom Sico

Division                                                                  Contact

 

30 West Spring St. L26 Columbus OH 43215-0000	614-466-6600	614-466-9384
Agency Mailing Address (Plus Zip)	Phone	Fax

 

 

4123-6-02.51

Rule Number

NEW

TYPE of rule filing

Rule Title/Tag Line              Provider access to the HPP -- Denial of provider, entity or

MCO certification based on criminal conviction or civil action..

RULE SUMMARY

1.  Is the rule being filed consistent with the requirements of the RC 119.032 review? No

2.  Are you proposing this rule as a result of recent legislation? Yes

Bill Number: SB7                   General Assembly: 126           Sponsor: Cates

3.  Statute prescribing the procedure in accordance with the agency is required to adopt the rule: 119.03

4.  Statute(s) authorizing agency to adopt the rule: 4121.12, 4121.121, 4121.30, 4123.31, 4123.05

5.  Statute(s) the rule, as filed, amplifies or implements: 4121.121, 4121.44, 4121.441, 4121.444, 4123.66

6.  State the reason(s) for proposing (i.e., why are you filing,) this rule:

To adopt provisions of S.B. 7 of the 126th General Assembly.

7.  If the rule is an AMENDMENT, then summarize the changes and the content of the proposed rule; If the rule type is RESCISSION, NEW or NO CHANGE, then summarize the content of the rule:

The proposed rule changes reflect that the Administrator may decertify (or refuse to certify or recertify) providers or MCOs who are owned by (more than 5%) or who have one or more officers, directors, partners, members, managing employees, etc. who have a felony conviction, a conviction under a federal controlled substance act, a misdemeanor conviction for an act involving dishonesty, fraud, or misrepresentation or committed in the course of practice, a felony or misdemeanor conviction involving dishonesty, fraud, or misrepresentation related to workers' compensation, or court supervised intervention or treatment in lieu of conviction.

Pursuant to newly-enacted Ohio Revised Code section 4121.444, the proposed rule changes also provide that the Administrator may terminate any agreement between the bureau and a person or a health care provider or managed care organization or its owner and cease reimbursement to that person, provider, organization, or owner if:

The person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization is convicted of or pleads guilty to a violation of sections 2913.48 (workers' compensation fraud) or 2923.31 to 2923.36 (engaging in a pattern of corrupt activity) of the Revised Code or any other criminal offense related to the delivery of or billing for health care benefits; or

There is an entry of judgment against the person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization and proof of the specific intent of the person, health care provider, managed care organization, or owner to defraud, in a civil action brought pursuant to newly-enacted Ohio Revised Code section 4121.444; or

There is an entry of judgment against the person, health care provider, managed care organization, or its owner, or an officer, authorized agent, associate, manager, or employee of a person, provider, or organization in a civil action brought pursuant to sections 2923.31 to 2923.36 of the Revised Code.

The proposed rule further provide, pursuant to newly-enacted Ohio Revised Code section 4121.444, that no person, health care provider, or managed care organization that has had its agreement with and reimbursement from the bureau terminated by the Administrator, or an owner, officer, authorized agent, associate, manager, or employee of that person, health care provider, or managed care organization shall either:

Directly provide services to any other bureau provider or have an ownership interest, as an individual or through any other entity or entities, of five percent or more in a provider of services that furnishes services to any other bureau provider; or

Arrange for, render, or order services for claimants during the period that the

agreement of the person, health care provider, managed care organization, or its owner is terminated as described in newly-enacted Ohio Revised Code section 4121.444.

8.  If the rule incorporates a text or other material by reference and the agency claims the incorporation by reference is exempt from compliance with sections

121.71 to 121.74 of the Revised Code because the text or other material is generally available to persons who reasonably can be expected to be affected by the rule, provide an explanation of how the text or other material is generally available to those persons:

This response left blank because filer specified online that the rule does not incorporate a text or other material by reference.

9.  If the rule incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material electronically, provide an explanation of why filing the text or other material electronically was infeasible:

This response left blank because filer specified online that the rule does not incorporate a text or other material by reference.

10.  If the rule is being rescinded and incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material, provide an explanation of why filing the text or other material was infeasible:

Not Applicable.

11.  If revising or refiling this rule, identify changes made from the previously filed version of this rule; if none, please state so:

The rule history has been changed to indicate that the rule also amplifies R.C. 4121.444.

12.  119.032 Rule Review Date:

(If the rule is not exempt and you answered NO to question No. 1, provide the scheduled review date. If you answered YES to No. 1, the review date for this rule is the filing date.)

NOTE: If the rule is not exempt at the time of final filing, two dates are required: the current review date plus a date not to exceed 5 years from the effective date for Amended rules or a date not to exceed 5 years from the review date for No

Change rules.

FISCAL ANALYSIS

13.  Estimate the total amount by which this proposed rule would increase / decrease either revenues / expenditures for the agency during the current biennium (in dollars): Explain the net impact of the proposed changes to the budget of your agency/department.

This will have no impact on revenues or expenditures. 0.00

N/A

14.  Identify the appropriation (by line item etc.) that authorizes each expenditure necessitated by the proposed rule:

N/A

15.  Provide a summary of the estimated cost of compliance with the rule to all directly affected persons. When appropriate, please include the source for your information/estimated costs, e.g. industry, CFR, internal/agency:

N/A

16.  Does this rule have a fiscal effect on school districts, counties, townships, or municipal corporations? No

17.  Does this rule deal with environmental protection or contain a component dealing with environmental protection as defined in R. C. 121.39? No