Bill Text: OR SB753 | 2013 | Regular Session | Introduced

Oregon Senate Bill 753 (Prior Session Legislation)

Bill Title: Relating to payment integrity for the state medical assistance program; declaring an emergency.

Spectrum: Slight Partisan Bill (Republican 15-5)

Status: (Failed) 2013-07-08 - In committee upon adjournment. [SB753 Detail]

Download: Oregon-2013-SB753-Introduced.html



     77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session

NOTE:  Matter within  { +  braces and plus signs + } in an
amended section is new. Matter within  { -  braces and minus
signs - } is existing law to be omitted. New sections are within
 { +  braces and plus signs + } .

LC 3631

                         Senate Bill 753

Sponsored by Senators KNOPP, KRUSE

                             SUMMARY

The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.

  Requires Oregon Health Authority to request specified
information from potential contractors and, if certain conditions
are met, to request proposals to establish and operate systems
and technologies designed to detect and prevent improper payments
in state medical assistance program.
  Declares emergency, effective on passage.

                        A BILL FOR AN ACT
Relating to payment integrity for the state medical assistance
  program; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
  SECTION 1.  { + The Legislative Assembly intends to:
  (1) Implement waste, fraud and abuse detection, prevention and
recovery solutions to improve payment integrity for the state
medical assistance program and create efficiency and cost savings
through a shift from a retrospective 'pay and chase' model to a
prospective prepayment model; and
  (2) Invest in the most cost-effective technologies and
strategies to yield the highest return on investment. + }
  SECTION 2.  { + (1) Not later than September 1, 2013, the
Oregon Health Authority shall issue a request for information
seeking input from potential contractors on the capabilities that
the authority lacks, functions the authority is not performing
and the costs of implementing:
  (a) Advanced predictive modeling and analytics technologies
integrated into the medical assistance claims processing system
to provide a comprehensive and accurate view across all
providers, recipients and geographic regions within the state
medical assistance program that will enable the authority to:
  (A) Identify and analyze billing or utilization patterns that
represent a high risk of fraudulent activity before payment is
made in order to minimize disruptions in claims processing
operations and speed the resolution of medical assistance claims;
  (B) Prioritize transactions identified as likely for potential
waste, fraud or abuse to receive additional review before payment
is made;
  (C) Obtain 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

  (D) 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.
  (b) Provider and recipient data verification and screening
technologies that use publicly available records for the purpose
of automating reviews and identifying and preventing
inappropriate payments by:
  (A) Identifying associations within and between providers and
provider groups that indicate potential collusive fraudulent
activity;
  (B) Identifying recipient attributes that indicate potential
ineligibility; and
  (C) Using fraud investigation services that combine
retrospective claims analysis and prospective waste, fraud or
abuse detection techniques. These services shall include analysis
of historical claims data, medical records, suspect provider
databases and high-risk identification lists, as well as direct
patient and provider interviews. Emphasis shall be placed on
providing education to providers and ensuring that providers have
the opportunity to review and correct any problems identified
prior to adjudication.
  (2) The authority may use the results of the request for
information to create a formal request for proposals to implement
the systems and technologies identified in this section if the
authority determines that:
  (a) Savings will be generated by preventing fraud, waste and
abuse;
  (b) The systems and technologies can be integrated into the
authority's current medical assistance claims processing
operations without incurring additional costs to the state; and
  (c) The reviews described in subsection (1)(b) of this section
are unlikely to delay or improperly deny payment of valid
claims. + }
  SECTION 3.  { + The Legislative Assembly intends that the
savings achieved through section 2 of this 2013 Act will exceed
the costs of implementation and administration. Therefore, to the
extent possible, technology services used in carrying out section
2 of this 2013 Act shall be secured using the savings generated
under section 2 of this 2013 Act, whereby the state's only direct
cost will be funded through the actual savings achieved. Further,
to enable this model, contractor reimbursement may be based on a
percentage of the achieved savings, or on the number of
recipients per month, the number of transactions per month, the
number of cases per month or a blend of any of these
methodologies. The contractor may be required to guarantee
performance that ensures that the savings identified exceed the
costs of implementing section 2 of this 2013 Act. + }
  SECTION 4.  { + This 2013 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2013 Act takes effect on its
passage. + }
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