Introduced Version
House Bill 2261 History
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Key: Green = existing Code. Red = new code to be enacted
H. B. 2261
(By Delegates Manypenny and Fleischauer)
[Introduced February 13, 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 section, designated §25-1-4a, relating to
requiring hospitals and other medical service providers to
bill Medicaid for eligible inmate hospital and professional
services.
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 section, designated §25-1-4a, to read as
follows:
ARTICLE 1. ORGANIZATION, INSTITUTIONS AND CORRECTIONS MANAGEMENT.
§25-1-4a. Requiring medical service providers outside division
facilities to bill Medicare.
_____(a) It is the intent of the Legislature to:
_____(1) Reduce the state's correctional health care costs by requiring hospitals and other medical service providers to bill
Medicaid for eligible inmate inpatient hospital and professional
services;
_____(2) Implement improper payment detection, prevention and
recovery solutions to reduce correctional health care costs by
introducing prospective solutions to eliminate overpayments and
retrospective solutions to recover those overpayments that have
already occurred;
_____(3) Cap noncontract correctional health care reimbursement
rates at one hundred and ten percent of Medicare; and
_____(4) Embrace technologies to better manage correctional health
care expenses.
_____(b) As used in this section, "Medicare" means the social
insurance program administered by the United States government,
established under Title XVIII of the Social Security Act of 1965.
_____(c) Unless otherwise stated, this section specifically applies
to correctional health care systems and services provided under
this article.
_____(d) The division shall cap noncontract payments to
correctional health care providers at one hundred and ten percent
of the federal Medicare reimbursement rate.
_____(e) To the maximum extent practicable, all noncontract
correctional health care claims shall be submitted to the division
in an electronic format.
_____(f) Hospitals and other medical service providers shall bill
Medicaid for all eligible inmate inpatient hospital and
professional services.
_____(g) The division 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 referenceable 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
pending or rejected claims and help ensure a smoother, more
consistent and more open adjudication process and fewer delays in
provider reimbursement.
_____(h) The division 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 correctional health care programs in order to:
_____(1) Assure that hospitals and medical service providers bill
Medicaid for all eligible inmate inpatient hospital and
professional services;
_____(2) Identify and analyze those billing or utilization patterns
that represent a high risk of inappropriate, inaccurate or erroneous activity;
_____(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
inappropriate, inaccurate or erroneous activity;
_____(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;
_____(6) Prevent the payment of claims for reimbursement that have
been identified as potentially inappropriate, inaccurate or
erroneous until the claims have been automatically verified as
valid; and
_____(7) Audit and recover improper payments made to providers
based upon inappropriate, inaccurate or erroneous billing or
payment activity.
_____(i) The division shall implement correctional health care
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 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 seventy-
two hour rule reviews, payment errors, billing errors and others.
_____(j) To implement the inappropriate, inaccurate or erroneous
detection, prevention and recovery solutions in this section, the
state shall either sign an intergovernmental agreement with another
state already receiving these services, contract with The
Cooperative Purchasing Network (TCPN) to issue a request for
proposals to select a contractor or use the following contractor
selection process:
_____(1) Not later than December 31, 2013, the division shall issue
a request for information to seek input from potential contractors
on capabilities and cost structures associated with the scope of
work of this section. The results of the request for information
shall be used by the division to create a formal request for
proposals to be issued within ninety days of the closing date of
the request for information;
_____(2) No later than ninety days after the close of the request
for information, the division shall issue a formal request for
proposals to carry out this section during the first year of
implementation. To the extent appropriate, the division may
include subsequent implementation years and may issue additional
requests for proposals with respect to subsequent implementation years;
_____(3) The division shall select contractors to carry out this
section using competitive procedures as provided in the state
purchasing guidelines;
_____(4) The division shall enter into a contract under this
section 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 section; or
_____(B) Has a contract, or will enter into a contract, with
another entity that meets the above criteria.
_____(5) The division shall only enter into a contract under this
section with an entity to the extent the entity complies with
conflict of interest standards in the state purchasing guidelines.
_____(k) The division shall provide entities with a contract under
this section with appropriate access to claims and other data
necessary for the entity to carry out the functions included in
this section. This includes, but is not limited to, providing
current and historical correctional health care claims and provider
database information; and taking necessary regulatory action to
facilitate appropriate public-private date sharing, including
across multiple correctional managed care entities.
_____(l) The following reports shall be completed by the division:
_____(1) Not later than three months after the completion of the first implementation year under this section, the division shall
submit to the appropriate committees of the Legislature 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 section during the year;
_____(B) A certification by the Division of Justice and Community
Services that specifies the actual and projected savings to state
correctional health care 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 in correctional health
care services 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 inappropriate inaccurate or erroneous activity;
_____(D) Any modifications or refinements that should be made to
increase the amount of actual or projected savings or mitigate any
adverse impact on correctional health care beneficiaries or
providers;
_____(E) An analysis of the extent to which the use of these
technologies successfully prevented and detected inappropriate,
inaccurate or erroneous activity in correctional health care
programs;
_____(F) A review of whether the technologies affected access to,
or the quality of, items and services furnished to correctional
health care beneficiaries; and
_____(G) A review of what effect, if any, the use of these
technologies had on correctional health care 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 section, the division shall
submit to the appropriate committees of the Legislature and make
available to the public a report that includes, with respect to
such year, the items required under subdivision (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 section, the division shall
submit to the appropriate committees of the Legislature, and make
available to the public, a report that includes with respect to
such year, the items required under subdivision (1), as well as any
other additional items determined appropriate with respect to the
report for such year.
_____(m) It is the intent of the Legislature that the savings
achieved through this section shall more than cover the costs of implementation. Therefore, to the extent possible, technology
services used in carrying out this section 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 section.
_____(n) If any section, paragraph, sentence, clause, phrase or any
part of the section passed is declared invalid, the remaining
sections, paragraphs, sentences, clauses, phrases, or parts thereof
shall be in no manner affected and shall remain in full force and
effect.
NOTE: The purpose of this bill is to require hospitals and
other medical service providers to bill Medicaid for eligible
inmate inpatient hospital and professional services.
This section is new; therefore, it has been completely
underscored.