Rep. Norm Thurston — Voting Record

Bill

Number

S.B. 227 (2019GS)

Sponsor

Sen. Anderegg, J.

Final action

Governor Signed 3/25/2019

Outcome

Became law — signed by Gov. Gary R. Herbert

Summary

What it does

• This bill:
• defines "waste";
• directs the Office of Inspector General of Medicaid Services (office) to submit a budget for the office directly to the Department of Administrative Services;
• amends required reporting of the office;
• requires the office to report to the Infrastructure and General Government Appropriations Subcommittee instead of the Executive Appropriations Committee; and
• makes technical and conforming changes.

Every vote on this bill

Bill text

MEDICAID INSPECTOR GENERAL AMENDMENTS
GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Jacob L. Anderegg
House Sponsor: 
Melissa G. Ballard
LONG TITLE
General Description:
This bill amends provisions related to the Office of Inspector General of Medicaid
Services.
Highlighted Provisions:
This bill:
▸ defines "waste";
▸ directs the Office of Inspector General of Medicaid Services (office) to submit a
budget for the office directly to the Department of Administrative Services;
▸ amends required reporting of the office;
▸ requires the office to report to the Infrastructure and General Government
Appropriations Subcommittee instead of the Executive Appropriations Committee;
and
▸ makes technical and conforming changes.
Money Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
AMENDS:
63A-13-102
, as last amended by Laws of Utah 2015, Chapter 135
63A-13-201
, as last amended by Laws of Utah 2015, First Special Session, Chapter 4
63A-13-502
, as last amended by Laws of Utah 2016, Chapter 222
Be it enacted by the Legislature of the state of Utah:
Section 1. Section 
63A-13-102
 is amended to read:
63A-13-102.
Definitions.
As used in this chapter:
(1) "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.
(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, created in Section 
26-1-4
.
(4) "Division" means the Division of Health Care Financing, created in Section
26-18-2.1
.
(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 intentional or knowing:
(a) deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, a
claim, reimbursement, or services; or
(b) a violation of a provision of Sections 
26-20-3
 through 
26-20-7
.
(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, 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) "Waste" means overutilization of resources or inappropriate payment.
]
(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.
Section 2. Section 
63A-13-201
 is amended to read:
63A-13-201.
Creation of office -- Inspector general -- Appointment -- Term.
(1) There is created an independent entity within the Department of Administrative
Services known as the "Office of Inspector General of Medicaid Services."
(2) The governor shall:
(a) appoint the inspector general of Medicaid services with the advice and consent of
the Senate; and
(b) establish the salary for the inspector general of Medicaid services based upon a
recommendation from the Department of Human Resource Management which shall be based
on a market salary survey conducted by the Department of Human Resource Management.
(3) A person appointed as the inspector general shall have the following qualifications:
(a) a general knowledge of the type of methodology and controls necessary to audit,
investigate, and identify fraud, waste, and abuse;
(b) strong management skills;
(c) extensive knowledge of performance audit methodology;
(d) the ability to oversee and execute an audit; and
(e) strong interpersonal skills.
(4) The inspector general of Medicaid services:
(a) shall serve a term of four years; and
(b) may be removed by the governor, for cause.
(5) If the inspector general is removed for cause, a new inspector general shall be
appointed, with the advice and consent of the Senate, to serve the remainder of the term of the
inspector general of Medicaid services who was removed for cause.
(6) The Office of Inspector General of Medicaid Services:
(a) is not under the supervision of, and does not take direction from, the executive
director, except for administrative purposes;
(b) shall use the legal services of the state attorney general's office;
(c) shall submit a budget for the office directly to the [
governor
] 
Department of
Administrative Services
;
(d) except as prohibited by federal law, is subject to:
(i) Title 51, Chapter 5, Funds Consolidation Act;
(ii) Title 51, Chapter 7, State Money Management Act;
(iii) Title 63A, Utah Administrative Services Code;
(iv) Title 63G, Chapter 3, Utah Administrative Rulemaking Act;
(v) Title 63G, Chapter 4, Administrative Procedures Act;
(vi) Title 63G, Chapter 6a, Utah Procurement Code;
(vii) Title 63J, Chapter 1, Budgetary Procedures Act;
(viii) Title 63J, Chapter 2, Revenue Procedures and Control Act;
(ix) Title 67, Chapter 19, Utah State Personnel Management Act;
(x) Title 67, Chapter 16, Utah Public Officers' and Employees' Ethics Act;
(xi) Title 52, Chapter 4, Open and Public Meetings Act;
(xii) Title 63G, Chapter 2, Government Records Access and Management Act; and
(xiii) coverage under the Risk Management Fund created under Section 
63A-4-201
;
(e) when requested, shall provide reports to the governor, the president of the Senate,
or the speaker of the House; and
(f) shall adopt administrative rules to establish policies for employees that are
substantially similar to the administrative rules adopted by the Department of Human Resource
Management.
Section 3. Section 
63A-13-502
 is amended to read:
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.
(2) The report shall include:
(a) non-identifying information, including statistical information, on:
(i) the items described in Subsection 
63A-13-202
(1)(b) and Section 
63A-13-204
;
(ii) 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[
;
and
]
, 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 [
Executive Appropriations
Committee
] 
Infrastructure and General Government Appropriations Subcommittee
 of the
Legislature and to the governor.