63A-13-502. Report and recommendations to governor and Infrastructure and General Government Appropriations Subcommittee.
(1)
The inspector general of Medicaid services shall, on an annual basis, prepare an electronic report on the activities of the office for the preceding fiscal year.
Terms Used In Utah Code 63A-13-502
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
Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
Fraud: Intentional deception resulting in injury to another.
Fraud: means an intentional or knowing:
(a)
deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, a claim, reimbursement, or services; or
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
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
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
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
(2)
The report shall include:
(a)
non-identifying information, including statistical information, on:
action taken by the office and the result of that action;
(iii)
fraud, waste, and abuse in the state Medicaid program, including emerging trends of Medicaid fraud, waste, and abuse and the office’s actions to identify and address the emerging trends;
(iv)
the recovery of fraudulent or improper use of state and federal Medicaid funds, including total dollars recovered through cash recovery, credit adjustments, and rebilled claims;
(v)
measures taken by the state to discover and reduce fraud, waste, and abuse in the state Medicaid program;
(vi)
audits conducted by the office, including performance and financial audits;
(vii)
investigations conducted by the office and the results of those investigations, including preliminary investigations;
(viii)
administrative and educational efforts made by the office and the division to improve compliance with Medicaid program policies and requirements;
(ix)
total cost avoidance attributed to an office policy or action;
(x)
the number of complaints against Medicaid recipients received and disposition of those complaints;
(xi)
the number of educational activities that the office provided to a provider or a state agency;
(xii)
the number of credible allegations of fraud referred to the Medicaid fraud control unit under Section 63A-13-501; and
(xiii)
the number of data pulls performed and general results of those pulls;
(b)
recommendations on action that should be taken by the Legislature or the governor to:
(i)
improve the discovery and reduction of fraud, waste, and abuse in the state Medicaid program;
(ii)
improve the recovery of fraudulently or improperly used Medicaid funds; and
(iii)
reduce costs and avoid or minimize increased costs in the state Medicaid program;
(c)
recommendations relating to rules, policies, or procedures of a state or local government entity; and
(d)
services provided by the state Medicaid program that exceed industry standards.
(3)
The report described in Subsection (1) may not include any information that would interfere with or jeopardize an ongoing criminal investigation or other investigation.
(4)
On or before November 1 of each year, the inspector general of Medicaid services shall provide the electronic report described in Subsection (1) to the Infrastructure and General Government Appropriations Subcommittee of the Legislature and to the governor.
