Revocation of certificate; suspension of new enrollment; suspension of the health care provider certificate; administrative fine; notice of action to the office; penalty for use of unlicensed providers.

(1) The agency may suspend the authority of an organization to enroll new subscribers or revoke the health care provider certificate of any organization, or order compliance within a time certain, if it finds that any of the following conditions exist:

(a) The organization is in substantial violation of its contracts.

(b) The organization is unable to fulfill its obligations under outstanding contracts entered into with its subscribers.

(c) The organization knowingly utilizes a provider who is furnishing or has furnished health care services and who does not have a subsisting license or other authority to practice or furnish health care services in this state.

(d) The organization no longer meets the requirements for the certificate as originally issued.

(e) The organization has violated any lawful rule or order of the agency or any provision of this part.

(f) The organization has refused to be examined or to produce its accounts, records, and files for examination or to perform any other legal obligation as to such examination, when required by the agency.

(g) The organization has not, after given reasonable notice, maintained accreditation or received favorable external quality assurance reviews under s. 641.512 or, following an investigation under s. 641.515, has been determined to not materially meet requirements under this part.

(2) Revocation of an organization’s certificate shall be for a period of 2 years. After 2 years, the organization may apply for a new certificate by compliance with all application requirements applicable to first-time applicants.

(3) Suspension of an organization’s authority to enroll new subscribers shall be for such period, not to exceed 1 year, as is fixed by the agency. The agency shall, in its order suspending the authority of an organization to enroll new subscribers, specify the period during which the suspension is to be in effect and the conditions, if any, which must be met by the organization prior to reinstatement of its authority to enroll new subscribers. The order of suspension is subject to rescission or modification by further order of the agency prior to the expiration of the suspension period. Authority to enroll new subscribers shall not be reinstated unless requested by the organization; however, the agency may not grant reinstatement if it finds that the circumstances for which the suspension of authority to enroll new subscribers occurred still exist or are likely to recur.

(4) The agency may suspend the health care provider certificate issued to an organization. The agency shall, in its order suspending the health care provider certificate, specify the period during which the suspension is to be in effect and the conditions, if any, which must be met by the organization for reinstatement. Upon expiration of the suspension period, the organization’s certificate automatically reinstates unless the agency finds that the causes of the suspension have not been removed or that the organization is otherwise not in compliance with this part. If the agency makes such a finding, the health care provider certificate shall not be reinstated and is considered to have expired as of the end of the suspension period.