Bill Text: GA SB63 | 2011-2012 | Regular Session | Engrossed
Bill Title: Georgia Medical Assistance Fraud Prevention Program; enact
Spectrum: Partisan Bill (Republican 6-0)
Status: (Engrossed - Dead) 2011-03-21 - House Second Readers [SB63 Detail]
Download: Georgia-2011-SB63-Engrossed.html
11 SB63/CSFA/1
Senate
Bill 63
By:
Senators Albers of the 56th, Ligon, Jr. of the 3rd, Bethel of the 54th, Staton
of the 18th, Miller of the 49th and others
AS
PASSED SENATE
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Chapter 4 of Title 49 of the Official Code of Georgia Annotated, relating
to public assistance, so as to enact the "Georgia Medical Assistance Fraud
Prevention Program"; to provide for the adoption of a medical assistance fraud
prevention program; to provide for definitions; to provide for implementation by
the Department of Community Health; to provide for implementation of a pilot
program; to provide for participation; to provide for cooperation by the
Department of Human Services; to provide for statutory construction; to provide
for certain matters to be referred to the Attorney General; to provide for a
waiver; to provide for related matters; to repeal conflicting laws; and for
other purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Chapter
4 of Title 49 of the Official Code of Georgia Annotated, relating to public
assistance, is amended by adding a new article to read as follows:
"ARTICLE
10
49-4-200.
This
article shall be known and may be cited as the 'Georgia Medical Assistance Fraud
Prevention Program.'
49-4-201.
As
used in this article, the term:
(1)
'Board' means the Board of Community Health established under Chapter 2 of Title
31.
(2)
'Care management organization' means an entity that is organized for the purpose
of providing or arranging health care, which has been granted a certificate of
authority by the Commissioner of Insurance as a health maintenance organization
pursuant to Chapter 21 of Title 33, and which has entered into a contract with
the department to provide or arrange health care services, products, or both on
a prepaid, capitated basis to members.
(3)
'Claim' includes any request or demand, whether under a contract or otherwise,
for money, property, or services, which is made to the Georgia Medicaid program,
or to any officer, employee, fiscal intermediary, grantee, or contractor of the
Georgia Medicaid program, or to other persons or entities if it results in
payments by the Georgia Medicaid program, if the Georgia Medicaid program
provides or will provide any portion of the money or property requested or
demanded, or if the Georgia Medicaid program will reimburse the contractor,
grantee, or other recipient for any portion of the money or property requested
or demanded. A claim includes a request or demand made orally, in writing,
electronically, or magnetically and:
(A)
Identifies a product or service provided or purported to have been provided
within the State of Georgia to a recipient as reimbursable under the medical
assistance program, without regard to whether the money that is requested or
demanded is paid;
(B)
States the income earned or expense incurred by a provider in providing a
product or a service and that is used to determine a rate of payment under the
medical assistance program; and
(C)
Has been generated at the point of transaction and as a result of recipients
participating in prescribed method of identity authentication as defined in
paragraph (2) of subsection (c) and paragraphs (1) and (2) of subsection (d) of
Code Section 49-4-203.
(4)
'Commissioner' means the commissioner of community health.
(5)
'Department' means the Department of Community Health established under Chapter
2 of Title 31.
(6)
'Health care provider' means any person, partnership, professional association,
corporation, facility, or institution certified, licensed, or registered by the
State of Georgia that has contracted with a care management organization to
provide health care services, products, or both to members.
(7)
'Medicaid' means the joint federal and state program of medical assistance
established by Title XIX of the federal Social Security Act, which is
administered in this state by the department pursuant to Article 7 of this
chapter.
(8)
'Medical assistance' means payment to a provider of a part or all of the cost of
certain items of medical or remedial care or service rendered by the provider to
a recipient, provided such items are rendered and received in accordance with
such provisions of Title XIX of the federal Social Security Act of 1935, as
amended, regulations promulgated pursuant thereto by the secretary of health and
human services, all applicable laws of this state, the state plan, and
regulations of the department which are in effect on the date on which the items
are rendered.
(9)
'Medical assistance card' means Medicaid cards currently used by recipients
prior to the implementation of the state-wide rollout pursuant to this article,
and which will be replaced by secure identification cards pursuant to this
article, which shall identify eligible recipients and their account numbers, and
shall be used by recipients to obtain medical assistance for which payment by
the state shall be tendered.
(10)
'Member' means a Medicaid or PeachCare for Kids recipient who is currently
enrolled in a care management organization plan.
(11)
'PeachCare for Kids' means the State of Georgia's State Children's Health
Insurance Program established pursuant to Title XXI of the federal Social
Security Act, which is administered in this state by the department pursuant to
Article 13 of Chapter 5 of this title.
(12)
'Physician' means a physician licensed to practice medicine in this state
pursuant to Chapter 34 of Title 43.
(13)
'Pilot program' means a proactive medical assistance fraud prevention pilot
program implemented pursuant to this article prior to a state-wide rollout of
the Georgia Medical Assistance Fraud Prevention Program.
(14)
'Point of transaction' means the act of a recipient obtaining a service,
product, or both provided by a provider, which service, product, or both is
submitted as a claim to be paid for by the Georgia Medicaid program as
established by Title XIX of the federal Social Security Act, which is
administered in this state by the Department of Community Health pursuant to
Article 7 of this chapter.
(15)
'Program' means the Georgia Medical Assistance Fraud Prevention Program
established and operated pursuant to this article.
(16)
'Provider' means a health care provider or provider of medical
assistance.
(17)
'Provider of medical assistance' means a person or institution, public or
private, including its employees, which possesses all licenses, permits,
certificates, approvals, registrations, charters, and other forms of permission
issued by entities other than the department, which forms of permission are
required by law either to render health care services, products, or both or to
receive medical assistance in which federal financial participation is available
and which meets the further requirements for participation prescribed by the
department and which is enrolled, in the manner and according to the terms
prescribed by the department, to participate in the state plan.
(18)
'Recipient' means a member or recipient of medical assistance.
(19)
'Recipient of medical assistance' means a person who has been certified
eligible, pursuant to the state plan, to have medical assistance paid on his or
her behalf.
(20)
'Secure identification card' means a card issued by the department pursuant to
Code Section 49-4-203.
(21)
'Service' includes care or treatment of recipients.
(22)
'State plan' means all documentation submitted by the commissioner on behalf of
the department to and for approval by the secretary of health and human
services, pursuant to Title XIX of the federal Social Security Act, as amended
(Act of July 30, 1965, P.L. 89-97, Stat. 343, as amended).
49-4-202.
(a)
The department shall establish and administer the Georgia Medical Assistance
Fraud Prevention Program. The board shall have the authority to enter into an
agreement with one or more third-party vendors for the purpose of implementing
and maintaining the program in accordance with this article.
(b)
Prior to a state-wide rollout of the program, the department shall conduct a
proactive medical assistance fraud prevention pilot program. The board shall
determine the scope of the pilot program and shall have the authority to enter
into an agreement with one or more third-party vendors for the purpose of
developing and executing the pilot program in accordance with this article.
Further, the board is authorized to establish such rules and regulations as may
be necessary or desirable in order to execute the pilot program.
(c)
The department shall implement a pilot program for not less than three months
and not more than six months, within three counties or municipalities. One
county or one municipality shall be from each of following population brackets
according to the United States Decennial Census of 2000: (1) 50,000 or less, (2)
100,000 to 250,000, and (3) more than 300,000. The pilot program shall involve
enrollment, distribution, and use of secure identification cards by all
recipients as replacements for currently used Medicaid assistance cards. The
pilot program shall involve verifying the status of each recipient of medical
assistance at the point of transaction including at least:
(1)
Verification of the authenticity of the recipient and the secure identification
card;
(2)
Verification that the secure identification card has not been reported lost,
stolen, revoked, or damaged;
(3)
Verification that the recipient of medical services remains eligible to receive
medical assistance prior to health care provider administering
service;
(4)
Verification that the health care provider is or remains eligible to administer
services to recipients of medical assistance; and
(5)
Verification by the recipient that one or more health care providers provided
the stated services.
(d)
The board shall mandate sufficient participation in the pilot program by
providers and recipients in the counties and municipalities in which the pilot
program is conducted to ensure proper evaluation of the pilot
results.
(e)
The department shall implement the pilot program not later than October 1,
2011.
49-4-203.
(a)
The department may implement the Georgia Medical Assistance Fraud Prevention
Program to address Medicaid fraud, waste, and abuse.
(b)
The program shall be designed to:
(1)
Authenticate recipients and their eligibility status at the onset and completion
of each point of transaction in order to prevent card sharing and other forms of
fraud and to confirm with the recipient that services were indeed administered
by one or more approved health care providers;
(2)
Deny ineligible persons at the point of transaction;
(3)
Authenticate providers of services including their eligibility status and each
recipient of medical assistance at the point of transaction to prevent phantom
billing and other forms of provider fraud;
(4)
Secure and protect the personal identity and information of recipients;
and
(5)
Reduce the total amount of medical assistance expenditures by reducing the
average cost per recipient.
(c)
The program shall include:
(1)
Secure identification cards issued to each recipient of medical assistance that
incorporate overt and covert security features which shall be blended with the
personal data printed on the card to form a significant barrier to imitation,
replication, and duplication. The secure identification cards shall incorporate
custom optical variable devices, demetalized optical variable devices, and a
color photograph of the recipient viewable under ambient light from the front
and back of the card incorporating microtext and unique alphanumeric
serialization specific to the eligible card holder. Other novel physical and
electronic security features that prevent the duplication, counterfeiting,
forging, or modification of the card may be employed as well that provide the
greatest security for the least amount of cost;
(2)
The assignment or personal selection of a unique personal identification number
or password for use by each recipient of medical assistance;
(3)
The assignment or personal selection of a unique personal identification number
or password for use by each health care provider administrator and point of
transaction operator;
(4)
Priority to the vendors that satisfies all of the requirements of this article
and requires the least amount of new infrastructure for the health care provider
and at the point of transaction thereby keeping program costs and the impact on
health care providers at a minimum;
(5)
A secure, web based information system for recording and reporting authenticated
transactions, including secure access, audit logging, and nonrepudiation to
support and validate each component and member in the system;
(6)
A secure, web based information system that interfaces with one or more systems
of record to determine eligibility of recipients and health care providers
that:
(A)
Exposes only the minimal and required personal privacy information data to
authorized parties;
(B)
Provides mechanisms for recipients and health care provider administrators to
manage and control their personal or organizational data; and
(C)
Fully complies with local, state, and federal privacy laws, including the
federal Health Insurance Portability and Accountability Act of 1996, P.L.
104-191.
(7)
A secure, web based information system that gathers analytical information in
order to assist in data-mining processes;
(8)
Priority to the vendors that requires the least amount of information to be
gathered and stored by the state, thereby reducing the liability and risk to the
state;
(9)
No requirement for preenrollment of recipients; and
(10)
A photograph of each recipient stored on the secure identification card and
information system data base, for viewing by health care providers at the point
of transaction prior to administrating services for the purposes of verifying
identity.
(d)
In implementing the program, the department may:
(1)
Enter and store billing codes, deductible amounts, and bill
confirmations;
(2)
Allow electronic prescribing services and prescription data base integration and
tracking in order to prevent medical error and to reduce pharmaceutical abuse
and lower health care costs through information sharing; and
(3)
Implement quick pay incentives for providers when electronic prescribing
services, electronic health records, electronic patient records, or computerized
patient records used by providers automatically synchronize with the information
system to electronically submit a claim.
(e)
The department may implement a state-wide rollout of the program after
completion of a successful pilot program. The pilot program shall be considered
a success if it meets the minimum criteria defined in subsections (b) and (c) of
this Code section and reduces the average monthly cost of recipients within the
pilot program area by a minimum of 5 percent. In the event that the pilot
program does not meet the minimum criteria to be considered a success, the
department may be authorized to extend and revise the pilot program as necessary
and to reevaluate the results. In order to evaluate the average monthly cost of
recipients within the pilot program and develop the strategy necessary to target
the highest rate of savings to the state plan, four sample sets of figures shall
be analyzed for the pilot program, including:
(1)
Establishment of base figures:
Claims
data for a first sample set shall be gathered which shall include all claims for
the recipients within the pilot program area and the average cost per recipient
by provider type and county or municipality from at least the prior year for the
exact time period for all areas in the pilot program;
(2)
Adjusted base figures for increase or decrease in cost of services:
In
order to evaluate increases or decreases in the cost of services, a second
sample set shall be gathered and adjusted to the base figures of the first
sample set. The second sample set of claims data shall represent a
corresponding county or municipality of a similar size not participating in the
pilot program, with as closely as possible the same demographics as the
population of recipients in the pilot program areas, including specific data
relating to sex, age, race, and ethnicity, county or municipality similarities,
number of providers, and the average cost per recipient. This sample set shall
be analyzed against the prior year's figures and compared to current year
figures for the same time frame and county or municipality to determine an
increase or decrease in cost of services. This sample shall not have any major
changes from the prior year to the current year that would change the
comparison, such as the introduction of managed care in the area. The increase
or decrease in cost per recipient from this sampling shall be factored into the
data set determined pursuant to paragraph (1) of this subsection to derive at an
adjusted base figure or average cost per recipient per month;
(3)
Comparison of base figures to current figures:
A
third sample set of data shall be gathered reflecting the claims data of the
recipients and the average cost per recipient on a monthly basis during the
pilot program by provider type. A comparison of the adjusted base figures
arrived at by the prior sampling with the actual figures from this third sample
set shall be made to determine how much the state saved by provider type.
Recipients leaving the pilot program area to avoid fraud detection will be
noted, thus, the third sample set will be adjusted by claims derived outside of
the pilot program area; and
(4)
Recipient surveying:
A
fourth sample set of data shall be obtained by sampling 2 percent of Georgia
Medicaid recipients in the pilot program area who shall be surveyed prior to the
start of the pilot program to acknowledge services used, frequency of services
used, and satisfaction of services used. This survey shall be taken again at
the completion of the pilot program to rate the level of satisfaction of the
pilot program.
(f)
The department shall adopt a plan to implement the program state wide in phases.
The
plan shall include for each phase:
(1)
A description of the policies and procedures concerning the handling of lost,
forgotten, stolen, and damaged secure identification cards, as well as
situations in which the recipient's identity cannot be confirmed;
(2)
A description of the policies and procedures for enrolling all recipients,
regardless of age, for participation in the program;
(3)
A description of the policies and procedures for distributing and activating
secure identification cards for all recipients; and
(4)
A description of the policies and procedures for implementing one or more
third-party vendor's solutions at health care provider locations, including
program management, distribution and installation, initial and ongoing training,
and initial and ongoing support and maintenance.
(g)
The board shall mandate participation in the program by all providers and
recipients
as
the program is rolled out.
49-4-204.
The
department, in preparation for implementing the pilot program required by this
article, shall submit a monthly report regarding the progress of
pre-implementation of the pilot program to the Governor, Lieutenant Governor,
Speaker of the House of Representatives, and presiding officer of each standing
committee of the Senate and House of Representatives having jurisdiction over
the Georgia Medicaid program. Upon implementation of the pilot program, a
quarterly report shall be submitted by the department. The first quarterly
report shall include an evaluation of the success of the pilot program, as
required by subsection (e) of Code Section 49-4-203.
49-4-205.
The
Department of Human Services shall cooperate and assist the department in the
process of adopting and administering both the program and the pilot
program.
49-4-206.
It
is the intention of the department that this article be construed consistent
with the federal Social Security Act, and any provision of this article found to
be in conflict with the federal Social Security Act shall be deemed to be void
and of no effect. It is further the intention of the department, in view of the
joint state and federal financial participation in the Georgia plan, that the
department shall be authorized to adopt such regulations as may be necessary to
comply with the requirements of the federal Social Security Act.
49-4-207.
The
department may refer matters to the Attorney General for handling pursuant to
Code Section 49-4-168.2 relating to possible violations of Article 7B of this
chapter.
49-4-208.
If,
before implementing any provision of this article, the department determines
that a waiver or authorization from a federal agency is necessary for
implementation of that provision, the department shall request the waiver or
authorization."
SECTION
2.
All
laws and parts of laws in conflict with this Act are repealed.
