Bill Text: HI SB323 | 2014 | Regular Session | Introduced
Bill Title: Medicaid; CHIP; Technology; Fraud; Waste; Abuse
Spectrum: Partisan Bill (Democrat 8-0)
Status: (Introduced - Dead) 2013-12-18 - Carried over to 2014 Regular Session. [SB323 Detail]
Download: Hawaii-2014-SB323-Introduced.html
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THE SENATE |
S.B. NO. |
323 |
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TWENTY-SEVENTH LEGISLATURE, 2013 |
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STATE OF HAWAII |
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A BILL FOR AN ACT
RELATING TO HEALTH INSURANCE.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:
SECTION 1. The legislature finds that the federal government has estimated that state medicaid programs pay around $18,000,000,000 annually due to fraud, waste, and abuse. In order to reduce this fraud, waste, and abuse, and save the associated state tax dollars that are lost to this fraud, waste, and abuse, it is the intent of the legislature to implement modern pre-payment prevention and recovery solutions.
SECTION 2. For the purposes of this section:
"CHIP" means the children's health insurance program established under Title XXI of the Social Security Act (42 U.S.C. 1397aa, et seq.).
"Medicaid" means the program to provide grants to states for medical assistance programs established under Title XIX of the Social Security Act (42 U.S.C. 1396, et seq.).
SECTION 3. This Act shall apply to state medicaid managed care programs, state medicaid programs, and the state CHIP program.
SECTION 4. The State shall incorporate provider data verification and provider screening technology solutions into the claims processing workflow to check current healthcare billing and provider rendering data against a continually maintained provider information database, automate reviews, identify and prevent inappropriate payments to deceased providers, identify sanctioned providers, note license expirations and retired providers, and identify wrong addresses.
SECTION 5. The State shall implement state-of-the-art predictive modeling and analytics technologies in a pre-payment position within the healthcare claim workflow to provide a more comprehensive and accurate view across all providers, beneficiaries, and geographies within the medicaid and CHIP programs and 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 CHIP 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 identified as potentially wasteful, fraudulent, or abusive until the claims have been automatically verified as valid.
SECTION 6. It is the intent of the legislature that the State shall contract for the services described in sections 4 and 5 of this Act and that the savings achieved through this Act shall more than cover the costs of implementation and administration. Therefore, to the extent possible, technology services used in carrying out this Act shall be secured using the savings generated by the program, whereby the State's only direct cost will be funded through the actual savings achieved. Further, to enable this model, reimbursement to the contractor may be contracted on the basis of a percentage of achieved savings model, a per beneficiary per month model, a peer transaction model, a case-rate model, or any blended model of the aforementioned methodologies. Reimbursement models with the contractor may also include performance guarantees of the contractor to ensure savings identified exceed program costs.
SECTION 7. If any provision of this Act, or the application thereof to any person or circumstance, is held invalid, the invalidity does not affect other provisions or applications of the Act that can be given effect without the invalid provision or application, and to this end the provisions of this Act are severable.
SECTION 8. This Act shall take effect upon its approval.
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INTRODUCED BY: |
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Report Title:
Medicaid; CHIP; Technology; Fraud; Waste; Abuse
Description:
Requires the State to implement certain cost-savings programs and technologies in the medicaid and children's health insurance programs to reduce fraud, waste, and abuse.
The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.
