26B-3-140.  Medical assistance accountability — Division duties — Reporting.

(1)  As used in this section:

Terms Used In Utah Code 26B-3-140

  • CMS: means the Centers for Medicare and Medicaid Services within the United States Department of Health and Human Services. See Utah Code 26B-3-101
  • Division: means the Division of Integrated Healthcare within the department, established under Section 26B-3-102. See Utah Code 26B-3-101
  • Fraud: Intentional deception resulting in injury to another.
  • Medicaid program: means the state program for medical assistance for persons who are eligible under the state plan adopted pursuant to Title XIX of the federal Social Security Act. See Utah Code 26B-3-101
  • Recipient: means a person who has received medical assistance under the Medicaid program. See Utah Code 26B-3-101
  • State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
(a)  “Abuse” means:

(i)  an action or practice that:

(A)  is inconsistent with sound fiscal, business, or medical practices; and

(B)  results, or may result, in unnecessary Medicaid related costs or other medical or hospital assistance costs; or

(ii)  reckless or negligent upcoding.

(b)  “Fraud” means intentional or knowing:

(i)  deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, claims, reimbursement, or practice; or

(ii)  deception or misrepresentation in relation to medical or hospital assistance funds, costs, claims, reimbursement, or practice.

(c)  “Upcoding” means assigning an inaccurate billing code for a service that is payable or reimbursable by Medicaid funds, if the correct billing code for the service, taking into account reasonable opinions derived from official published coding definitions, would result in a lower Medicaid payment or reimbursement.

(d)  “Waste” means overutilization of resources or inappropriate payment.

(2)  The division shall:

(a)  develop and implement procedures relating to Medicaid funds and medical or hospital assistance funds to ensure that providers do not receive:

(i)  duplicate payments for the same goods or services;

(ii)  payment for goods or services by resubmitting a claim for which:

(A)  payment has been disallowed on the grounds that payment would be a violation of federal or state law, administrative rule, or the state plan; and

(B)  the decision to disallow the payment has become final;

(iii)  payment for goods or services provided after a recipient‘s death, including payment for pharmaceuticals or long-term care; or

(iv)  payment for transporting an unborn infant;

(b)  consult with CMS, other states, and the Office of Inspector General of Medicaid Services to determine and implement best practices for discovering and eliminating fraud, waste, and abuse of Medicaid funds and medical or hospital assistance funds;

(c)  actively seek repayment from providers for improperly used or paid:

(i)  Medicaid funds; and

(ii)  medical or hospital assistance funds;

(d)  coordinate, track, and keep records of all division efforts to obtain repayment of the funds described in Subsection (2)(c), and the results of those efforts;

(e)  keep Medicaid pharmaceutical costs as low as possible by actively seeking to obtain pharmaceuticals at the lowest price possible, including, on a quarterly basis for the pharmaceuticals that represent the highest 45% of state Medicaid expenditures for pharmaceuticals and on an annual basis for the remaining pharmaceuticals:

(i)  tracking changes in the price of pharmaceuticals;

(ii)  checking the availability and price of generic drugs;

(iii)  reviewing and updating the state’s maximum allowable cost list; and

(iv)  comparing pharmaceutical costs of the state Medicaid program to available pharmacy price lists; and

(f)  provide training, on an annual basis, to the employees of the division who make decisions on billing codes, or who are in the best position to observe and identify upcoding, in order to avoid and detect upcoding.

Renumbered and Amended by Chapter 306, 2023 General Session

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