2014 -- S 2219

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2014

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A N   A C T

RELATING TO STATE AFFAIRS AND GOVERNMENT -- MEDICAID FRAUD AND

WASTE PREVENTION

     Introduced By: Senators Crowley, Sosnowski, Miller, Pearson, and Jabour

     Date Introduced: January 30, 2014

     Referred To: Senate Finance

     It is enacted by the General Assembly as follows:

     SECTION 1. Title 42 of the General Laws entitled “STATE AFFAIRS AND

GOVERNMENT" is hereby amended by adding thereto the following chapter:

CHAPTER 14.7

MEDICAID, RITE CARE AND RITE SHARE FRAUD AND WASTE REDUCTION

     42-14.7-1. Short title. – This act shall be known as and may be cited as the “Medicaid

and RIte Care and RIte Share Fraud and Waste Reduction Act.”

     42-14.7-2. Legislative intent. – It is the intent of the general assembly to implement

modern pre-payment prevention and recovery solutions to combat waste attributed to fraud, waste

and abuse within Medicaid and the RIte Care and RIte Share programs.

     42-14.7-3. Definitions. – The definitions in this section shall apply throughout this

chapter unless the context requires otherwise:

     (1) “Medicaid” means the program to provide grants to states for medical assistance

programs established under title XIX of the Social Security Act (42 USC 1396 et seq.).

     (2) “RIte Care” and “RIte Share” means the children’s health insurance program

established under title XXI of the Social Security Act (42 USC 1397aa et seq.).

     42-14.7-4. Application. – This chapter shall specifically apply to:

     (1) State Medicaid managed care programs operated under this chapter or chapter 5.1 or

chapter 12.3 of title 42 of the Rhode Island general laws.

     (2) The RIte Care and RIte Share state programs operated under Rhode Island general

laws, chapter 40-8.4.

     42-14.7-5. Data verification. – The state shall implement provider data verification and

provider screening technology solutions into the claims processing workflow to check healthcare

billing and provider rendering data against a continually maintained provider information

database for the purposes of automating reviews and identifying and preventing inappropriate

payments to:

     (1) Deceased providers;

     (2) Sanctioned providers;

     (3) License expiration/retired providers; and

     (4) Confirmed wrong addresses.

     42-14.7-6. Predictive modeling. – The state shall implement state-of-the-art predictive

modeling and analytics technologies in a position within the healthcare claim workflow to

provide a more comprehensive and accurate view across all providers, beneficiaries and

geographies within the Medicaid, RIte Care and RIte Share programs in order to:

     (1) Identify and analyze those billing or utilization patterns that represent a high risk of

fraudulent activity;

     (2) Be integrated into the existing Medicaid and RIte Care and RIte Share claims

workflow;

     (3) Undertake and automate such analysis before payment is made to minimize

disruptions to the workflow and speed claim resolution;

     (4) Prioritize such identified transactions for additional review before payment is made

based on likelihood of potential waste, fraud or abuse;

     (5) Capture outcome information from adjudicated claims to allow for refinement and

enhancement of the predictive analytics technologies based on historical data and algorithms

within the system; and

     (6) Prevent the payment of claims for reimbursement that have been indentified as

potentially wasteful, fraudulent or abusive until the claims have been automatically verified as

valid.

     42-14.7-7. Cost of implementation to be offset by savings. – The state may contract for

services in order to comply with the provisions of this chapter; provided, however, that the cost of

implementation of the provisions of this chapter shall be offset by savings generated by the

reduction of fraud and waste within the state Medicaid, RIte Care and RIte Share programs.

     42-14.7-8. Severability. – If any provision of this chapter or the application thereof to

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any person or circumstances is held invalid, such invalidity shall not affect other provisions or

applications of the chapter, which can be given effect without the invalid provisions or

applications, and to this end the provisions of this chapter are declared to be severable.

     SECTION 2. This act shall take effect upon passage.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO STATE AFFAIRS AND GOVERNMENT -- MEDICAID FRAUD AND

WASTE PREVENTION

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     This act would implement fraud and waste detection and reduction solutions within the

state Medicaid, RIte Care and RIte Share programs.

     This act would take effect upon passage.

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