Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
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. See Utah Code 63A-13-102
Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
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
United States: includes each state, district, and territory of the United States of America. See Utah Code 68-3-12.5
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. See Utah Code 63A-13-102
(a)
administer, direct, and manage the office;
(b)
inspect and monitor the following in relation to the state Medicaid program:
(i)
the use and expenditure of federal and state funds;
(ii)
the provision of health benefits and other services;
(iii)
implementation of, and compliance with, state and federal requirements; and
(iv)
records and recordkeeping procedures;
(c)
receive reports of potential fraud, waste, or abuse in the state Medicaid program;
(d)
investigate and identify potential or actual fraud, waste, or abuse in the state Medicaid program;
(e)
consult with the Centers for Medicaid and Medicare Services and other states to determine and implement best practices for:
(i)
educating and communicating with health care professionals and providers about program and audit policies and procedures;
(ii)
discovering and eliminating fraud, waste, and abuse of Medicaid funds; and
(iii)
differentiating between honest mistakes and intentional errors, or fraud, waste, and abuse, if the office enters into settlement negotiations with the provider or health care professional;
(f)
obtain, develop, and utilize computer algorithms to identify fraud, waste, or abuse in the state Medicaid program;
(g)
work closely with the fraud unit to identify and recover improperly or fraudulently expended Medicaid funds;
(h)
audit, inspect, and evaluate the functioning of the division for the purpose of making recommendations to the Legislature and the department to ensure that the state Medicaid program is managed:
(i)
in the most efficient and cost-effective manner possible; and
(ii)
in a manner that promotes adequate provider and health care professional participation and the provision of appropriate health benefits and services;
(i)
regularly advise the department and the division of an action that could be taken to ensure that the state Medicaid program is managed in the most efficient and cost-effective manner possible;
(j)
refer potential criminal conduct, relating to Medicaid funds or the state Medicaid program, to the fraud unit;
identify, prevent, and reduce fraud, waste, and abuse in the state Medicaid program; and
(ii)
balance efforts to reduce costs and avoid or minimize increased costs of the state Medicaid program with the need to encourage robust health care professional and provider participation in the state Medicaid program;
report on the actions and findings of the inspector general; and
(ii)
make recommendations to the Legislature and the governor;
(p)
provide training to:
(i)
agencies and employees on identifying potential fraud, waste, or abuse of Medicaid funds; and
(ii)
health care professionals and providers on program and audit policies and compliance; and
(q)
develop and implement principles and standards for the fulfillment of the duties of the inspector general, based on principles and standards used by:
(i)
the Federal Offices of Inspector General;
(ii)
the Association of Inspectors General; and
(iii)
the United States Government Accountability Office.
(2)
(a)
The office may, in fulfilling the duties under Subsection (1), conduct a performance or financial audit of:
(i)
a state executive branch entity or a local government entity, including an entity described in Section 63A-13-301, that:
(A)
manages or oversees a state Medicaid program; or
(B)
manages or oversees the use or expenditure of state or federal Medicaid funds; or
(ii)
Medicaid funds received by a person by a grant from, or under contract with, a state executive branch entity or a local government entity.
(b)
(i)
The office may not, in fulfilling the duties under Subsection (1), amend the state Medicaid program or change the policies and procedures of the state Medicaid program.
(ii)
The office shall identify conflicts between the state Medicaid plan, department administrative rules, Medicaid provider manuals, and Medicaid information bulletins and recommend that the department reconcile inconsistencies. If the department does not reconcile the inconsistencies, the office shall report the inconsistencies to the Legislature’s Administrative Rules Review and General Oversight Committee created in Section 63G-3-501.
(iii)
Beginning July 1, 2013, the office shall review a Medicaid provider manual and a Medicaid information bulletin in accordance with Subsection (2)(b)(ii), prior to the department making the provider manual or Medicaid information bulletin available to the public.
(c)
Beginning July 1, 2013, the Department of Health shall submit a Medicaid provider manual and a Medicaid information bulletin to the office for the review required by Subsection (2)(b)(ii) prior to releasing the document to the public. The department and the Office of Inspector General of Medicaid Services shall enter into a memorandum of understanding regarding the timing of the review process under Subsection (2)(b)(iii).
(3)
(a)
The office shall, in fulfilling the duties under this section to investigate, discover, and recover fraud, waste, and abuse in the Medicaid program, apply the state Medicaid plan, department administrative rules, Medicaid provider manuals, and Medicaid information bulletins in effect at the time the medical services were provided.
(b)
A health care provider may rely on the policy interpretation included in a current Medicaid provider manual or a current Medicaid information bulletin that is available to the public.
(4)
The inspector general of Medicaid services, or a designee of the inspector general of Medicaid services within the office, may take a sworn statement or administer an oath.
