Introduced Version
House Bill 3036 History
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Key: Green = existing Code. Red = new code to be enacted
H. B. 3036
(By Delegate Manypenny (By Request))
[Introduced March 21, 2013; referred to the
Committee on Health and Human Resources then Finance.]
A BILL to amend the Code of West Virginia, 1931, as amended, by
adding thereto a new article, designated §9-7A-1, §9-7A-2,
§9-7A-3, §9-7A-4, §9-7A-5, §9-7A-6, §9-7A-7, §9-7A-8, §9-7A-9,
§9-7A-10, §9-7A-11, §9-7A-12 and §9-7A-13, all relating to
improving program integrity for Medicaid and the Children's
Health Insurance Program by implementing additional waste,
fraud and abuse, prevention, detection and recovery solutions.
Be it enacted by the Legislature of West Virginia:
That the Code of West Virginia, 1931, as amended, be amended
by adding thereto a new article, designated §9-7A-1, §9-7A-2,
§9-7A-3, §9-7A-4, §9-7A-5, §9-7A-6, §9-7A-7, §9-7A-8, §9-7A-9,
§9-7A-10, §9-7A-11, §9-7A-12 and §9-7A-13, all to read as follows:
ARTICLE 7A. IMPROVING PROGRAM INTEGRITY FOR MEDICAID AND THE
CHILDREN'S HEALTH INSURANCE PROGRAM.
§9-7A-1. Legislative purpose and findings.
_____It is the intent of the Legislature to implement additional
waste, fraud and abuse detection, prevention and recovery solutions
to enhance existing programs such as the Medicare Fraud Unit
established in article seven of this chapter to:
_____(1) Improve program integrity for Medicaid and the Children's
Health Insurance Program in the state and create efficiency and
cost savings through a shift from a retrospective "pay and chase"
model to a prospective prepayment model; and
_____(2) Comply with program integrity provisions of the federal
Patient Protection and Affordable Care Act and the Health Care and
Education Reconciliation Act of 2010, as promulgated in the Centers
for Medicare and Medicaid Services Final Rule 6028.
§9-7A-2. Definitions.
_____As used in this article:
_____(1) "Medicaid" means the program to provide grants to states
for medical assistance programs established under title XIX of the
Social Security Act (42 U.S.C. 1396 et seq.).
_____(2) "CHIP" means the Children's Health Insurance Program
established under title XXI of the Social Security Act (42 U.S.C.
1397aa et seq.).
_____(3) "Enrollee" means an individual who is eligible to receive
benefits and is enrolled in either the Medicaid or CHIP programs.
_____(4) "Secretary" means the U.S. Secretary of Health and Human Services, acting through the Administrator of the Centers for
Medicare and Medicaid Services.
_____(5) "Department" means the West Virginia Department of Health
and Human Resources.
§9-7A-3. Application.
_____This article shall specifically apply to:
_____(1) State Medicaid managed care programs operated under the
provisions of this chapter;
_____(2) State Medicaid programs operated under the provisions of
this chapter; and
_____(3) The state CHIP program operated under the provisions of
article sixteen-b, chapter five of this code. The department shall
coordinate with the Department of Administration when implementing
any provision of this article with respect to the state CHIP
program.
§9-7A-4. Implementation generally.
_____The department shall implement provider data verification and
provider screening technology solutions to check healthcare billing
and provider rendering data against a continually maintained
provider information database for the purposes of automating
reviews and identifying and preventing inappropriate payments to:
_____(1) Deceased providers;
_____(2) Sanctioned providers;
_____(3) License expiration/retired providers; and
_____(4) Confirmed wrong addresses.
§9-7A-5. Implementation of clinical code editing technology
solutions.
_____The department shall implement state-of-the art clinical code
editing technology solutions to further automate claims resolution
and enhance cost containment through improved claim accuracy and
appropriate code correction. The technology shall identify and
prevent errors or potential overbilling based on widely accepted
and transparent protocols such as the American Medical Association
and the Centers for Medicare and Medicaid Services. The edits shall
be applied automatically before claims are adjudicated to speed
processing and reduce the number of pended or rejected claims and
help ensure a smoother, more consistent and more transparent
adjudication process and fewer delays in provider reimbursement.
§9-7A-6. Implementation of predictive modeling and analytics
technologies.
_____The department shall implement state-of-the-art predictive
modeling and analytics technologies to provide a more comprehensive
and accurate view across all providers, beneficiaries and
geographies within the Medicaid and CHIP programs in order to:
_____(1) Identify and analyze those billing or utilization patterns
that represent a high risk of fraudulent activity;
_____(2) Be integrated into the existing Medicaid and CHIP claims workflow;
_____(3) Undertake and automate such analysis before payment is
made to minimize disruptions to the workflow and speed claim
resolution;
_____(4) Prioritize such identified transactions for additional
review before payment is made based on likelihood of potential
waste, fraud or abuse;
_____(5) Capture outcome information from adjudicated claims to
allow for refinement and enhancement of the predictive analytics
technologies based on historical data and algorithms within the
system; and
_____(6) Prevent the payment of claims for reimbursement that have
been identified as potentially wasteful, fraudulent or abusive
until the claims have been automatically verified as valid.
§9-7A-7. Integration of retrospective claims analysis and
prospective detection techniques.
_____The department shall implement fraud investigative services
that combine retrospective claims analysis and prospective waste,
fraud or abuse detection techniques. These services shall include
analysis of historical claims data, medical records, suspect
provider databases and high-risk identification lists, as well as
direct patient and provider interviews. Emphasis shall be placed on
providing education to providers and ensuring that they have the
opportunity to review and correct any problems identified prior to adjudication.
§9-7A-8. Implementation of Medicaid and CHIP claims audit and
recovery services.
_____The department shall implement Medicaid and CHIP claims audit
and recovery services to identify improper payments due to
nonfraudulent issues, audit claims, obtain provider sign-off on the
audit results and recover validated overpayments. Post payment
reviews shall ensure that the diagnoses and procedure codes are
accurate and valid based on the supporting physician documentation
within the medical records. Core categories of reviews could
include: Coding Compliance Diagnosis Related Group (DRG) Reviews,
Transfers, Readmissions, Cost Outlier Reviews, Outpatient 72-Hour
Rule Reviews, Payment Errors, Billing Errors and others.
§9-7A-9. Selection of contractor.
_____To implement this article, the department shall either
contract with The Cooperative Purchasing Network (TCPN) to issue an
RFP to select a contractor or use the following contractor
selection process:
_____(1) Not later than January 1, 2014, the department shall issue
a request for information (RFI) to seek input from potential
contractors on capabilities and cost structures associated with the
scope of work of this article. The results of the RFI shall be used
by the department to create a formal request for proposals (RFP) to
be issued within ninety days of the closing date of the RFI.
_____(2) No later than ninety days after the close of the RFI, the
department shall issue a formal RFP to carry out this article
during the first year of implementation. To the extent appropriate,
the department may include subsequent implementation years and may
issue additional RFPs with respect to subsequent implementation
years.
_____(3) The department shall select contractors to carry out this
article using competitive procedures as provided in article three,
chapter five-a of this code.
_____(4) The department may enter into a contract under this
article with an entity only if the entity:
_____(A) Can demonstrate appropriate technical, analytical and
clinical knowledge and experience to carry out the functions
included in this article; or
_____(B) Has a contract, or will enter into a contract, with
another entity that meets the above criteria.
_____(5) The department may only enter into a contract under this
article with an entity to the extent the entity complies with state
procurement conflict of interest standards.
§9-7A-10. Access to data.
_____The department shall provide entities with a contract under
this article with appropriate access to claims and other data
necessary for the entity to carry out the functions included in
this article. This includes, but is not limited to: providing current and historical Medicaid and CHIP claims and provider
database information; and taking necessary regulatory action to
facilitate appropriate public-private data sharing, including
across multiple Medicaid managed care entities.
§9-7A-11. Report and certification.
_____(1) The following reports shall be completed by the
department:
_____Not later than three months after the completion of the first
implementation year under this article, the department shall submit
to the Legislature's Joint Committee on Government and Finance and
make available to the public a report that includes the following:
_____(A) A description of the implementation and use of
technologies included in this article during the year;
_____(B) A certification by department that specifies the actual
and projected savings to the Medicaid and CHIP programs as a result
of the use of these technologies, including estimates of the
amounts of such savings with respect to both improper payments
recovered and improper payments avoided;
_____(C) The actual and projected savings to the Medicaid and CHIP
programs as a result of such use of technologies relative to the
return on investment for the use of such technologies and in
comparison to other strategies or technologies used to prevent and
detect fraud, waste, and abuse;
_____(D) Any modifications or refinements that should be made to increase the amount of actual or projected savings or mitigate any
adverse impact on Medicare beneficiaries or providers;
_____(E) An analysis of the extent to which the use of these
technologies successfully prevented and detected waste, fraud, or
abuse in the Medicaid and CHIP programs;
_____(F) A review of whether the technologies affected access to,
or the quality of, items and services furnished to Medicaid and
CHIP beneficiaries; and
_____(G) A review of what effect, if any, the use of these
technologies had on Medicaid and CHIP providers, including
assessment of provider education efforts and documentation of
processes for providers to review and correct problems that are
identified.
_____(2) Not later than three months after the completion of the
second implementation year under this article, the department shall
submit to the Legislature's Joint Committee on Government and
Finance and make available to the public a report that includes,
with respect to such year, the items required under (1) as well as
any other additional items determined appropriate with respect to
the report for such year.
_____(3) Not later than three months after the completion of the
third implementation year under this article, the department shall
submit to the Legislature's Joint Committee on Government and
Finance, and make available to the public, a report that includes with respect to such year, the items required under (1), as well as
any other additional items determined appropriate with respect to
the report for such year.
§9-7A-12. Shared savings model.
_____It is the intent of the Legislature that the savings achieved
through this article shall more than cover the costs of
implementation. Therefore, to the extent possible, technology
services used in carrying out this article shall be secured using
a shared savings model, whereby the state's only direct cost will
be a percentage of actual savings achieved. Further, to enable
this model, a percentage of achieved savings may be used to fund
expenditures under this article.
§9-7A-13. Effective date. This article takes effect on July 1,
2013.
NOTE: The purpose of this bill is to
improve program integrity
for Medicaid and the Children's Health Insurance Program by
implementing additional waste, fraud and abuse, prevention,
detection and recovery solutions
.
This article is new; therefore, it has been completely
underscored.