In this subtitle the following words have the meanings indicated. “Abuse” means provider practices that are inconsistent with sound fiscal, business, or medical practices and result in unnecessary costs to a program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized health care standards. “Claim” means a request or demand for money, property, or services made under contract or otherwise, by a contractor, grantee, provider, or other person seeking money for the provision of health services if: The State or Department provides any portion of the money or property that is requested or demanded; or The State or Department reimburses the contractor, grantee, provider, or other person for any portion of the money or property that is requested or demanded. “Employee” means any individual who performs services for, or under the control or direction of, a provider for wages or other remuneration. “Fraud” means an intentional material deception or misrepresentation made by a person with the knowledge that the deception or misrepresentation could result in some unauthorized benefit or payment. “Fraud” includes any act that constitutes fraud under applicable State or federal law. “Office” means the Maryland Office of the Inspector General for Health established under § 2–502 of this subtitle. “Program” means the Medical Assistance Program, the Cigarette Restitution Fund Program, the Developmental Disabilities Administration, the Behavioral Health Administration, the Prevention and Health Promotion Administration, or any other unit of the Department that pays a provider for a service rendered or claimed to have been rendered to a recipient. “Provider” means: An individual licensed or certified under the Health Occupations Article to provide health care; A licensed facility that provides health care to individuals; Any other person who or entity that provides health care, products, or services to a program recipient; or A contractor, subcontractor, or vendor who directly or indirectly provides the Department or its recipients supplies, drugs, equipment, or services. “Provider” does not include a State agency that receives grant funding from or through the Department if that agency has in place a corporate compliance program that meets departmental requirements. “Recipient” means an individual who receives benefits under a program. “Recovery” means the repayment of money to the Department by a provider through return, reimbursement, recoupment, withholding of future payments, offsets, or any other method.

There is a Maryland Office of the Inspector General for Health. The Office is an independent unit of the State. Subject to paragraph (2) of this subsection, the Office shall have access to the following services of the Department: Information technology; Budget and finance; Human resources; Police; Procurement; and Support services. The Office shall, in consultation with the Department, develop policies and adopt regulations regarding the use and confidentiality of the services listed in paragraph (1) of this subsection. The Office shall: Maintain a physical location within the Department; and Develop policies and adopt regulations regarding the use and confidentiality of the location of the Office.

There is an Inspector General in the Maryland Office of the Inspector General for Health. An individual is eligible to be the Inspector General only if the individual executes an affidavit stating that the individual will not accept appointment to, or be a candidate for, a State or local office: During the period of service as the Inspector General; and For at least 3 years immediately after the individual last serves as the Inspector General. The Inspector General shall renew the affidavit every 2 years during the period of service. A failure to renew the affidavit under this subsection shall subject the Inspector General to removal from office under this section. The Inspector General shall be appointed unanimously by the Governor, the Attorney General, and the State Treasurer, subject to the advice and consent of the Senate. The term of the Inspector General is 5 years, beginning July 1 after the appointment of the Inspector General. At the end of a term, the Inspector General shall continue to serve until a successor is appointed. If a vacancy occurs in the Office, an interim Inspector General shall be appointed as successor to serve for the remainder of the unexpired term. The Inspector General may be removed unanimously by the Governor, the Attorney General, and the State Treasurer for: Misconduct in office; Persistent failure to perform the duties of the Office; or Conduct prejudicial to the proper administration of justice. Subject to paragraph (2) of this subsection, the Inspector General must be professionally qualified through experience or education in at least one of the following areas: Law; Auditing; Government operations; Financial management; or Health policy. If the Inspector General is professionally qualified in the area of health policy, the Inspector General also must be professionally qualified through experience or education in at least one of the other areas listed in paragraph (1) of this subsection. The Inspector General is entitled to the salary provided in the State budget. Funding for the Office shall be as provided in the State budget.

There is a Compliance Officer within the Maryland Office of the Inspector General for Health. The Compliance Officer shall be designated by the Inspector General. The Compliance Officer shall be professionally qualified through experience or education in at least one of the following areas: Administrative management; Health care compliance standards; or Public health. The Compliance Officer shall ensure that units and employees of the Department comply with: Best practices in health care, public health, and government administration; and Laws, regulations, and Department policies.

The Inspector General: May investigate fraud, waste, abuse of departmental funds, and behavior in the Department that threatens public safety or demonstrates negligence, incompetence, or malfeasance; Shall cooperate with and coordinate investigative efforts with the Medicaid Fraud Control Unit and where a preliminary investigation establishes a sufficient basis to warrant referral, shall refer such matters to the Medicaid Fraud Control Unit; and Shall cooperate with and coordinate investigative efforts with departmental programs and other State and federal agencies to ensure a provider is not subject to duplicative audits. The Inspector General or a designated Assistant Inspector General may subpoena any person or evidence, administer oaths, and take depositions and other testimony for the purpose of investigating fraud, waste, abuse of departmental funds, or behavior in the Department that threatens public safety or demonstrates negligence, incompetence, or malfeasance. If a person fails to comply with a lawful order or subpoena issued under this subsection, on petition of the Inspector General or a designated Assistant Inspector General, a court of competent jurisdiction may compel: Compliance with the order or subpoena; or Testimony or the production of evidence. Within 30 business days after receiving a complaint or allegation, the Inspector General, the Compliance Officer, or a designated Assistant Inspector General shall respond to the individual who filed the complaint or allegation with: A preliminary indication of whether the Office of the Inspector General is able to investigate the complaint or allegation; and If the Office of the Inspector General is unable to investigate the complaint or allegation: The reason for not being able to investigate, unless providing the reason would have a negative impact on or jeopardize an investigation being conducted by the Office of the Inspector General, a managed care organization, another unit of government, or law enforcement; and The contact information for the Office of Legislative Audits Fraud Hotline.

The Inspector General, in collaboration with the appropriate departmental program, may: Take necessary steps to recover any mistaken claims paid or payments obtained in error or fraudulent claims paid to or obtained by a provider; and Take necessary steps to recover the cost of benefits mistakenly paid or obtained in error, or fraudulently paid to or obtained by a recipient.

Except as otherwise prohibited by State or federal law, in the sole discretion of the Inspector General, the Inspector General may impose a civil money remedy against a provider for a violation of State or federal law governing the conditions of payment for any service or item for which the provider submitted a claim for payment and received payment. A civil money remedy imposed under this section: Is in lieu of full payment or full adjustment of the paid claim and not in addition to repayment of the claim; May not be less than the federal financial participation share of the identified improper claim amount; May not be imposed if the claim was included in the universe of claims under an extrapolation calculation; and Is only available if the provider has not been subjected to a repayment penalty or fine, a criminal action, or a civil false claims action under either federal or State law for the same claim. A civil money remedy may not exceed the amount of reimbursement that the provider received for the paid claim. In determining whether to impose a civil money remedy under this section and in setting the amount of the civil money remedy, the Inspector General shall consider: The number, nature, and seriousness of the violations; The provider’s history of compliance; The efforts made by the provider to correct the violations and any continuation of conduct after notification of possible violations; The provider’s level of cooperation with the Department or Inspector General as it relates to the review of the claim; The degree of risk to the health, life, or safety of consumers as a result of the violations; and Any other reasonable factors as fairness may require. In weighing the factors set forth in paragraph (2) of this subsection, the Inspector General shall, if appropriate, give special consideration to the extent to which the provider’s size, operations, or financial condition: May have contributed to the violations; and May affect the provider’s ability to provide care and continue operations after payment of a civil money remedy. If a civil money remedy is imposed under this section, the Inspector General shall issue a written notice and order to the provider that: States the total amount of the civil money remedy; and Includes the following information: The basis on which the order is made; Each regulation or statute violated; The amount of each civil money remedy imposed for each violation; The number of claims and total value of the claims identified with errors; and The manner in which the amount of the civil money remedy was calculated. The notice and order shall be served on the provider by certified mail and shall include a statement that explains the provider’s right to appeal the order in accordance with Title 10, Subtitle 2 of the State Government Article. An order that imposes a civil money remedy is final when the provider has exhausted all opportunities to contest the civil money remedy in accordance with Title 10, Subtitle 2 of the State Government Article. After exhaustion of all appeals, a provider shall pay a civil money remedy to the Department within 10 days after the provider receives a final order that affirms the imposition of the civil money remedy unless the Inspector General negotiates and approves a repayment schedule. The Inspector General, in consultation with stakeholders, shall adopt regulations to implement this section.

A person is not civilly liable for: Making a report in good faith of fraud, waste, or abuse; or Participating in any investigation related to fraud, waste, or abuse. This subsection does not apply to an employee as defined in § 1–501(c) of the Health Occupations Article or a State employee. A provider may not take a retaliatory action against an employee because the employee: Discloses or threatens to disclose to a supervisor or to a public body an activity, policy, or practice of the provider that the employee reasonably believes is in violation of this subtitle or a regulation adopted under this subtitle; Provides information to, or testifies before, a public body conducting an investigation, hearing, or inquiry into a suspected violation by the provider under this subtitle or a regulation adopted under this subtitle; or Objects to or refuses to participate in any activity, policy, or practice that the employee reasonably believes is in violation of this subtitle or regulations adopted under this subtitle. Any employee who is subject to an action in violation of paragraph (2) of this subsection may institute a civil action in the county where: The alleged violation occurred; The employee resides; or The provider maintains its principal office in the State. The action shall be brought within 1 year after the alleged violation of paragraph (2) of this subsection or within 1 year after the employee first became aware of the alleged violation of paragraph (2) of this subsection. In any action brought under this subsection, a court may: Issue an injunction to restrain continued violation of this subsection; Reinstate the employee to the same or an equivalent position held before the violation of paragraph (2) of this subsection; Remove any adverse personnel record entries based on or related to the violation of paragraph (2) of this subsection; Reinstate full fringe benefits and seniority rights; Require compensation for lost wages, benefits, and other remuneration; and Assess reasonable attorney’s fees and other litigation expenses against: The provider, if the employee prevails; or The employee, if the court determines that the action was brought by the employee in bad faith and without basis in law or fact. A provider shall: Conspicuously display notices of its employee protections under this subsection; and Use appropriate means to inform its employees of the protections and obligations provided under this subsection.

On or before December 1 each year, the Office shall submit a report to the Secretary, the Governor, and, in accordance with § 2–1257 of the State Government Article, the Senate Budget and Taxation Committee, the Senate Finance Committee, the House Appropriations Committee, the House Health and Government Operations Committee, and the Joint Audit and Evaluation Committee on: The Office’s activities during the immediately preceding fiscal year, including: Investigations of fraud, waste, and abuse of departmental funds undertaken by the Office, including specific findings and recommendations related to the investigations; A summary of matters referred to the Medicaid Fraud Control Unit by the Office; Recoveries by the Office of mistaken claims paid or payments obtained in error or fraudulent claims paid to or obtained by a provider; Recoveries by the Office of the cost of benefits mistakenly paid or obtained in error, or fraudulently paid to or obtained by a recipient; and A summary of matters referred to prosecutive authorities and the resulting prosecutions and convictions; and Any regulatory or statutory changes necessary to ensure compliance with applicable federal and State laws.