Utah Code 63A-13-204. Selection and review of claims
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Terms Used In Utah Code 63A-13-204
- Abuse: means :(1)(a) an action or practice that:(1)(a)(i) is inconsistent with sound fiscal, business, or medical practices; and(1)(a)(ii) results, or may result, in unnecessary Medicaid related costs; or(1)(b) reckless or negligent upcoding. See Utah Code 63A-13-102
- Allegation: something that someone says happened.
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Department: means the Department of Health and Human Services created in Section 26B-1-201. See Utah Code 63A-13-102
- 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. See Utah Code 63A-13-102
- Fraud: Intentional deception resulting in injury to another.
- Fraud: means an intentional or knowing:
(6)(a) deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, a claim, reimbursement, or services; or(6)(b) violation of a provision of Sections 26B-3-1102 through 26B-3-1106. See Utah Code 63A-13-102- Fraud unit: means the Medicaid Fraud Control Unit of the attorney general's office. 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:
(11)(a) medical assistance, including supplies or services, in exchange, directly or indirectly, for Medicaid funds; or(11)(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
- Statute of limitations: A law that sets the time within which parties must take action to enforce their rights.
- Waste: includes an activity that:
(13)(b)(i) does not constitute abuse or necessarily involve a violation of law; and(13)(b)(ii) relates primarily to mismanagement, an inappropriate action, or inadequate oversight. See Utah Code 63A-13-102(1)(a) The office shall periodically select and review a representative sample of claims submitted for reimbursement under the state Medicaid program to determine whether fraud, waste, or abuse occurred.(1)(b) The office shall limit its review for waste and abuse under Subsection (1)(a) to 36 months prior to the date of the inception of the investigation or 72 months if there is a credible allegation of fraud. In the event the office or the fraud unit determines that there is fraud as defined in Section 63A-13-102, then the statute of limitations defined in Section 26B-3-1115 shall apply.(2) The office may directly contact the recipient of record for a Medicaid reimbursed service to determine whether the service for which reimbursement was claimed was actually provided to the recipient of record.(3) The office shall:(3)(a) generate statistics from the sample described in Subsection (1) to determine the type of fraud, waste, or abuse that is most advantageous to focus on in future audits or investigations;(3)(b) ensure that the office, or any entity that contracts with the office to conduct audits:(3)(b)(i) has on staff or contracts with a medical or dental professional who is experienced in the treatment, billing, and coding procedures used by the type of provider being audited; and(3)(b)(ii) uses the services of the appropriate professional described in Subsection (3)(b)(i) if the provider that is the subject of the audit disputes the findings of the audit;(3)(c) ensure that a finding of overpayment or underpayment to a provider is not based on extrapolation, unless:(3)(c)(i) there is a determination that the level of payment error involving the provider exceeds a 10% error rate:(3)(c)(i)(A) for a sample of claims for a particular service code; and(3)(c)(i)(B) over a three year period of time;(3)(c)(ii) documented education intervention has failed to correct the level of payment error; and(3)(c)(iii) the value of the claims for the provider, in aggregate, exceeds $200,000 in reimbursement for a particular service code on an annual basis; and(3)(d) require that any entity with which the office contracts, for the purpose of conducting an audit of a service provider, shall be paid on a flat fee basis for identifying both overpayments and underpayments.(4)(4)(a) If the office, or a contractor on behalf of the department:(4)(a)(i) intends to implement the use of extrapolation as a method of auditing claims, the department shall, prior to adopting the extrapolation method of auditing, report its intent to use extrapolation:(4)(a)(i)(A) to the Social Services Appropriations Subcommittee; and(4)(a)(i)(B) as required under Section 63A-13-502; and(4)(a)(ii) determines Subsections (3)(c)(i) through (iii) are applicable to a provider, the office or the contractor may use extrapolation only for the service code associated with the findings under Subsections (3)(c)(i) through (iii).(4)(b)(4)(b)(i) If extrapolation is used under this section, a provider may, at the provider’s option, appeal the results of the audit based on:(4)(b)(i)(A) each individual claim; or(4)(b)(i)(B) the extrapolation sample.(4)(b)(ii) Nothing in this section limits a provider’s right to appeal the audit under Title 63G, Chapter 4, Administrative Procedures Act, the Medicaid program and its manual or rules, or other laws or rules that may provide remedies to providers.