63A-13-102.  Definitions.
     As used in this chapter:

(1)  “Abuse” means:

Terms Used In Utah Code 63A-13-102

  • Abuse: means :
(a) an action or practice that:
(i) is inconsistent with sound fiscal, business, or medical practices; and
(ii) results, or may result, in unnecessary Medicaid related costs; or
(b) reckless or negligent upcoding. See Utah Code 63A-13-102
  • Department: means the Department of Health and Human Services created in Section 26B-1-201. See Utah Code 63A-13-102
  • Division: means the Division of Integrated Healthcare, created in Section 26B-3-102. See Utah Code 63A-13-102
  • Inspector general: means the inspector general of the office, appointed under Section 63A-13-201. See Utah Code 63A-13-102
  • Office: means the Office of Inspector General of Medicaid Services, created in Section 63A-13-201. See Utah Code 63A-13-102
  • Oversight: Committee review of the activities of a Federal agency or program.
  • Person: means :Utah Code 68-3-12.5
  • 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. See Utah Code 63A-13-102
    • (a)  an action or practice that:

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

    (ii)  results, or may result, in unnecessary Medicaid related costs; or

    (b)  reckless or negligent upcoding.

    (2)  “Claimant” means a person that:

    (a)  provides a service; and

    (b)  submits a claim for Medicaid reimbursement for the service.

    (3)  “Department” means the Department of Health and Human Services created in Section 26B-1-201.

    (4)  “Division” means the Division of Integrated Healthcare, created in Section 26B-3-102.

    (5)  “Extrapolation” means a method of using a mathematical formula that takes the audit results from a small sample of Medicaid claims and projects those results over a much larger group of Medicaid claims.

    (6)  “Fraud” means an intentional or knowing:

    (a)  deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, a claim, reimbursement, or services; or

    (b)  violation of a provision of Sections 26B-3-1102 through 26B-3-1106.

    (7)  “Fraud unit” means the Medicaid Fraud Control Unit of the attorney general’s office.

    (8)  “Health care professional” means a person licensed under:

    (a)  Title 58, Chapter 5a, Podiatric Physician Licensing Act;

    (b)  Title 58, Chapter 16a, Utah Optometry Practice Act;

    (c)  Title 58, Chapter 17b, Pharmacy Practice Act;

    (d)  Title 58, Chapter 24b, Physical Therapy Practice Act;

    (e)  Title 58, Chapter 31b, Nurse Practice Act;

    (f)  Title 58, Chapter 40, Recreational Therapy Practice Act;

    (g)  Title 58, Chapter 41, Speech-Language Pathology and Audiology Licensing Act;

    (h)  Title 58, Chapter 42a, Occupational Therapy Practice Act;

    (i)  Title 58, Chapter 44a, Nurse Midwife Practice Act;

    (j)  Title 58, Chapter 49, Dietitian Certification Act;

    (k)  Title 58, Chapter 60, Mental Health Professional Practice Act;

    (l)  Title 58, Chapter 67, Utah Medical Practice Act;

    (m)  Title 58, Chapter 68, Utah Osteopathic Medical Practice Act;

    (n)  Title 58, Chapter 69, Dentist and Dental Hygienist Practice Act;

    (o)  Title 58, Chapter 70a, Utah Physician Assistant Act; and

    (p)  Title 58, Chapter 73, Chiropractic Physician Practice Act.

    (9)  “Inspector general” means the inspector general of the office, appointed under Section 63A-13-201.

    (10)  “Office” means the Office of Inspector General of Medicaid Services, created in Section 63A-13-201.

    (11)  “Provider” means a person that provides:

    (a)  medical assistance, including supplies or services, in exchange, directly or indirectly, for Medicaid funds; or

    (b)  billing or recordkeeping services relating to Medicaid funds.

    (12)  “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.

    (13) 

    (a)  “Waste” means the act of using or expending a resource carelessly, extravagantly, or to no purpose.

    (b)  “Waste” includes an activity that:

    (i)  does not constitute abuse or necessarily involve a violation of law; and

    (ii)  relates primarily to mismanagement, an inappropriate action, or inadequate oversight.

    Amended by Chapter 329, 2023 General Session

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