No. 37536 (Repeal and Reenact): Rule R367-1. Office of Inspector General of Medicaid Services

(Repeal and Reenact)

DAR File No.: 37536
Filed: 04/24/2013 09:06:54 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule change implements the provisions required by H.B. 106 and H.B. 315 (2013 General Session). The Office of the Inspector General of Medicaid Services is moved from R367, Governor, Planning and Budget, Inspector General of Medicaid Services (Office of) to R30, Administrative Services, Inspector General of Medicaid Services (Office of).

Summary of the rule or change:

This rule change implements the provisions required by H.B. 106 and H.B. 315 (2013). The Office of the Inspector General (OIG) is repealing its previous administrative rule under Title R367 and reenacting it under Title R30. The Office is eliminating several redundant rules and incorporations by reference. The Office is removing provisions pertaining to billing codes, confidentiality, discrimination, and several statutes and regulations that are incorporated by reference. These provisions are not needed as they are redundant and imposed on the Office by other laws. This administrative rule is designed to simplify and clarify how the Office is to operate. The new rule implements how the Office will communicate with providers, conduct audits, make reports to law enforcement and execute the duties imposed by law. The new rule creates provisions regarding on-site visits, and training. Additionally, the rule implements a 36-month time frame for investigations and audits. The rule clarifies how policy is enforced and in accordance with the new provisions of H.B. 106 and H.B. 315 (2013). Lastly, the rule implements the human resource rules that the Office will use.

State statutory or constitutional authorization for this rule:

• Sections 63A-11-1 through 63A-11-602

Anticipated cost or savings to:

the state budget:

The implementation of Rule R30-2 will not have any aggregate cost to the state budget. The rule further clarifies the duties and procedures of the Office of Inspector General outlined in Sections 63A-13-101 through 63A-13-602. No other expense is created by the issuance of this rule. There will be savings to the state budget, as this rule will further assist the OIG to recoup and recovery misappropriated Medicaid funds. This amount will vary year to year based upon the results of the audits.

local governments:

The promulgation of this rule will not result in direct and measurable costs for local governments. Local governments are not involved in the Medicaid Program. Additionally, the OIG will be collecting wrongfully acquired Medicaid funds. These are funds that the local governments were not originally entitled to; any funds paid by the local government, if any, would be a reimbursement of state and federal money.

small businesses:

The promulgation of this rule will not result in direct and measurable costs for small businesses. The OIG will be collecting wrongfully acquired Medicaid funds from small and solo practice medical providers. These are funds that the providers were not originally entitled to; any monies paid by the providers to the OIG, if any, would be a reimbursement of state monies.

persons other than small businesses, businesses, or local governmental entities:

The promulgation of this rule will not result in direct and measurable costs for other entities. The OIG will be collecting wrongfully acquired Medicaid funds from hospitals, large provider groups, pharmacies. These are funds that the providers were not originally entitled to; any monies paid by the providers to the OIG, if any, would be a reimbursement of state monies. Therefore there would be no additional costs to small businesses, just a reimbursement to the state.

Compliance costs for affected persons:

Rule R30-1 does not create new compliance costs for any local government or business. There are no regulatory mandates created by this rule. The rule establishes the OIG's new duties, audit responsibilities, and procedures. Due to this there is no cost created by the implementation of this rule.

Comments by the department head on the fiscal impact the rule may have on businesses:

Rule R30-1 does not create any additional costs to local governments or any businesses. The rule will outline the daily operations of the Office of Inspector General. The Office will seek to recover recoupment of wrongfully or erroneously acquired Medicaid funds. The entities that inappropriately received the monies do not incur additional costs, other than a reimbursement to the state of the money they were not otherwise entitled to. Further, entities and providers that are assessed a recoupment may have this recoup offset by future payments. This will minimize the impact to daily operations of the provider. The fiscal impact of Rule R30-1 follows the analysis conducted by the Office of Legislative Fiscal Analyst report for H.B. 84, which founded the office in July of 2011.

Lee Wyckoff, Inspector General

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Governor
Planning and Budget, Inspector General of Medicaid Services (Office of)
288 N 1460 W
Salt Lake City, UT 84116

Direct questions regarding this rule to:

• Michael Green at the above address, by phone at 801-538-6123, by FAX at 801-538-6382, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

06/14/2013

This rule may become effective on:

06/21/2013

Authorized by:

Michael Green, Policy and Training Coordinator

RULE TEXT

[ R367. Governor, Planning and Budget, Inspector General of Medicaid Services (Office of).

R367-1. Office of Inspector General of Medicaid Services.

R367-1-1. Introduction and Authority.

(1) This rule generally characterizes the scope of the Office of Inspector General of Medicaid Services in Utah, and defines all of the provisions necessary to administer the Office.

(2) The rule is authorized under Section 63J-4a-602 pursuant to Title 63G, Chapter 3, Utah Administrative Rulemaking Act.

(3) If any provider manual or policy guide is inconsistent with Administrative Rule, the Administrative Rule shall be supreme.

 

R367-1-2. Definitions.

(1) The terms used in this rule are defined in Section 63J-4a-102.

 

R367-1-3. The Office of Inspector General.

(1) The Utah Department of Health is the Single State Agency designated to administer or supervise the administration of the Medicaid program under Title XIX of the federal Social Security Act, The Office of Inspector General must ensure that the Medicaid Program is managed in an efficient and effective manner to minimize fraud, waste, and abuse, in the Medicaid program as outlined in Section 63J-4a-202. The Office of Inspector General has entered into a Memorandum of Understanding (MOU) with the Department outlining the delegation of duties from the Department to the Office and as required by federal and state statutes.

 

R367-1-4. Office Duties.

(1) The Office of the Inspector General shall perform the following duties:

(a) Adhere to appropriate standards as outlined in the Government Accounting Office's Government Auditing Standards.

(b) The Office will receive reports of potential fraud, waste, or abuse in the state Medicaid program through phone, website, or other electronic means open to the public:

(i) establish a 24-hour, toll free hotline monitored by staff, or voicemail as appropriate.

(ii) establish a separate identifiable email to report fraud, waste or abuse of Medicaid funds.

(c) The Office will investigate and identify potential or actual fraud, waste, or abuse in the state Medicaid program by post payment review of claims paid under fee-for service, managed care, capitation, waiver, contracts or other payment methods where funds are expended by the Department for Medicaid related services or programs.

(d) The Office will obtain, develop, and utilize computer algorithms to identify fraud, waste, or abuse in the state Medicaid program by either developing an in-house program, by contract with private vendors, or other suitable methods as agreed upon with the Department. The Office may also develop in-house programs in consultation with the Department.

(e) The Office will establish an MOU with the Medicaid Fraud Control Unit to identify and recover improperly or fraudulently expended Medicaid funds.

(f) The Office will determine appropriate methodology for identifying risk associated with the Division and its programs under Medicaid funding.

(g) The Office will regularly report to the Department regarding all identified cases of fraud, waste or abuse. The Office will report how the Department can reduce cost or improve performance through changes in policies or claims payment systems. The Office will operate the program integrity function and audit function to the extent possible and as described under a MOU with the Department to be established each state fiscal year beginning in July and ending In June of the following year. The MOU must be renewed each year by both the DOH and OIG.

(h) The Office will establish a means for providers to return payments to the Office. The Office will return all collected overpayments to the Department, except to pay Recovery Audit Contractors.

(i) The Office will provide training to agencies, providers and employees on identifying potential fraud, waste, or abuse of Medicaid funds regularly. All training materials and curriculum will be developed in consultation with the Department and may include Department representation.

 

R367-1-5. Incorporations by Reference.

(1) All rules, regulations, and laws below are incorporated by reference.

(a) 42 CFR 431.107(b)(2)

(b) 42 CFR 456, Subpart B

(c) 42 CFR 455.13

(d) 42 CFR 455.21

(e) 42 CFR 1007

(f) Title 63G, Chapter 2

(g) Title 26-1-17.5

(h) Section 26-1-24

(i) Section 63G-4-102

(j) 42 USC 139a(a)(3)

(k) 42 CFR 431, Subpart E

 

R367-1-6. Discrimination Prohibited.

(1) In accordance with Title VI of the Civil Rights Act of 1964 (42 USC 2000d et seq.), Section 504 of the Rehabilitation Act of 1973 (29 USC 70b), and the regulations at 45 CFR Parts 80 and 84, the Office assures that no individual shall be subjected to discrimination under the plan on the grounds of race, color, gender, national origin, or handicap.

 

R367-1-7. Utilization Review and Medicaid Services Provided under the Utah Medicaid Program.

(1) The Office may request records that support provider claims for payment under programs funded through the Department. These requests shall be in writing and identify the records to be reviewed. Written responses to requests must be returned within 30 days of the date of the written request. Responses must include the complete record of all services and supporting services for which reimbursement is claimed. If the provider is unable to produce the documents on request, the provider shall be granted 24 hours to provide all necessary and appropriate information supporting and documenting the need for services. However, if there is no response within the 30 day period, the Office will close the record and will evaluate the payment based on the records available.

(2) The Office may conduct announced or unannounced onsite reviews and visits. On-site reviews require that the provider submit records on request based on 42 CFR 431.107(b)(2). All announced visits will receive reasonable notice from the Office.

(3) The Office shall conduct hospital utilization reviews as outlined in the Department's Superior System Waiver in effect at the time service was rendered.

(a) The Office shall determine medical necessity and appropriateness of inpatient admissions during utilization review by use of InterQual criteria, published by McKesson Corporation.

(b) The standards in the InterQual criteria, or other suitable industry standard substitute, shall not apply to services in which a determination has been made to utilize criteria customized by the Department or that are excluded as a Medicaid benefit by rule or contract.

(c) Where InterQual or other suitable industry standard substitute criteria are silent, the Office shall approve or deny services based upon appropriate administrative rules or the Department's criteria as incorporated in the Medicaid provider manuals.

(4) Providers shall refund payments to the Office upon written request if any of the following occur:

(a) the Department pays for a service which is later determined not to be a benefit of the Utah Medicaid program; or

(b) does not comply with state or federal policies and regulations.

(c) If services cannot be properly verified or when a provider refuses to provide or grant access to records.

(d) Unless appealed, all refunds must be made to the Office within 30 days of written notification. An appeal of this determination must be filed within 30 days of written notification as specified in Rule R367-1-14.

(e) A provider shall reimburse the Office for all overpayments regardless of the reason for the overpayment. Including, but not limited to agency errors, inadvertent errors, or other program errors. The Office may make a request to the Department to deduct an equal amount from future reimbursements.

 

R367-1-9. Medicaid Fraud.

(1) The Office establishes and maintains methods, criteria, and procedures that meet all federal and state requirements for prevention, control of program fraud and abuse; and provider sanctioning and termination.

(2) The Office will enter into an MOU with The Medicaid Fraud Control Unit and the Department to ensure appropriate measures are established to reduce and prevent fraud and abuse in the Medicaid program.

 

R367-1-10. Confidentiality.

(1) Title 63G, Chapter 2, and Section 26-1-17.5 impose legal sanctions and provide safeguards that restrict the use or disclosure of information concerning providers, applicants, clients, and recipients to purposes directly connected with the administration of the plan. The Office will adopt those principles through incorporation of the references note.

 

R367-1-11. Right to Contract with Recovery Audit Organizations.

(1) The Office may contract for the investigation, notification and recovery of overpayments under any funds paid by the Department through the Medicaid program, Title XIX of the Social Security Act, under a contingency fee arrangement not to exceed the maximum amount set by CMS of the state's share actually recovered from overpayments according to federal regulations.

 

R367-1-12. Auditing of the Department of Health.

12.1. Audit Responsibilities.

(1) Audits will be conducted under the regular supervision of the Inspector General.

(2) The audit reports will then be released to the Director of the Governor's Office of Planning and Budget to which the Inspector General reports administratively.

(3) Audits will primarily be determined through a risk assessment approved by the Office.

(4) All activities of the Office will remain free of influence from any Department, Division, private or contracted entities.

(5) The Office audit group will follow the Generally Accepted Government Auditing Standards (GAGAS) as it relates to audit standards and training.

(6) The auditors will immediately notify the Inspector General of any serious deficiency or the suspicion of significant fraud during its review.

(7) Pursuant to Utah Code 63J-4a-301 the Office will have unrestricted access to all records of state executive branch entities, all local government entities, and all providers relating directly or indirectly to the state Medicaid program.

12.2. Audit Plan.

(1) An audit plan will be prepared by the Office at least annually and shall:

(a) Identify the audits to be performed, based on audit risk assessment reviewed annually;

(b) Identify resources to be devoted to audits in plan;

(c) Ensure that audits evaluate the efficiency and effectiveness of tax payer dollars in the Medicaid program;

(d) Determine adequacy of Medicaid's controls over federal and state compliance.

(2) An OIG audit shall:

(a) Issue regular audit reports on the effectiveness and efficiency of the defined audits within the Medicaid program in Utah;

(b) Ensure that such audits are conducted within professional standards such as those defined by the Institute of Internal Auditors and Generally Accepted Governmental Auditing Standards (GAGAS);

(c) Report annually to the Governor's office on or before October 1, and to the Utah Legislature before November 30 as stated in Section 63J-4a-502.

12.3. Access to Records and Employees.

(1) In order to fulfill the duties described in Section 63J-4a-202, the Office shall have unrestricted access to all records of state executive branch entities, all local government entities, and all providers relating, directly or indirectly, as stated in 63J-4a-301. Access to employees that the inspector general determines may assist in the fulfilling of the duties of the Office shall be granted as stated in 63J-4a-302.

12.4. Subpoena Power.

(1) The Office shall have the power to issue a subpoena to obtain record or interview a person that the Office has the right to access as stated in 63J-4a-401.

 

R367-1-13. Billing Codes.

(1) In submitting claims to the Department, every provider shall use billing codes compliant with Health Insurance Portability and Accountability Act of 1996 (HIPAA), along with other national accredited coding standards as defined under the federal law or other nationally accepted coding standards and as established under the Affordable Care Act of 2010 which requires all Medicaid providers to bill according to National Correct Coding Initiatives (N.C.C.I) that are in effect at the time of submitting claims to the Medicaid Agency for payments.

 

R367-1-14. Provider Communication.

(1) In completing the work as outlined in 63J-4a-202(k), to identify and recoup overpayments, the Office will communicate overpayments information as follows:

(a) Any suspected recoupment or take back against future funds less than $5,000 shall be communicated to the provider via email including a verification certificate attached to verify delivery.

(b) Any suspected recoupment or take back against future funds greater than $5,000 shall be communicated to the provider through certified mail or similar guaranteed delivery mechanism.

(c) Administrative hearing notice requirements will also comply with (a) and (b) above.

(d) In addition to the methods set forth in this rule, a party may be served as permitted by the Utah Rules of Civil Procedure.

(2) Any request for records or documents will also comply with subsections (a) through (d).

 

R367-1-16. General Rule Format.

(1) The following format is used generally throughout the rules of the Office. Section headings as indicated and the following general definitions are for guidance only. The section headings are not part of the rule content itself. In certain instances, this format may not be appropriate and will not be implemented due to the nature of the subject matter of a specific rule.

(2) Introduction and Authority. A concise statement as to what Medicaid service is covered by the rule, and a listing of specific federal statutes and regulations and state statutes that authorize or require the rule.

(3) Definitions. Definitions that have special meaning to the particular rule.

(4) Other Sections. As necessary under the particular rule, additional sections may be indicated. Other sections include regulatory language that does not fit into sections (1) through (4).

 

KEY: Inspector General, health, Medicaid fraud waste abuse

Date of Enactment or Last Substantive Amendment: December 27, 2012

Authorizing, and Implemented or Interpreted Law: 63J-4a-101; 63J-4a-201; 63J-4a-602 ]

R30. Administrative Services, Inspector General of Medicaid Services (Office of).

R30-1. Office of Inspector General of Medicaid Services.

R30-1-1. Introduction and Authority.

(1) This rule generally characterizes the scope of the Office of Inspector General of Medicaid Services in Utah, and defines all of the provisions necessary to administer the Office.

(2) The rule is authorized under Utah Code Annotated Section 63A-13-602 pursuant to Title 63G, Chapter 3, Utah Administrative Rulemaking Act.

 

R30-1-2. Definitions.

(1) The terms used in this rule are defined in Section 63A-13-102.

(2) Policy is defined as the Utah State Plan, Medicaid Administrative rule, provider manuals and their attachments, and the Medicaid Information Bulletins.

 

R30-1-3. The Office of Inspector General.

(1) The Office of Inspector General shall inspect and monitor the Utah Medicaid Program pursuant to Section 63A-13-202.

(2) The Office of Inspector General has entered into a Memorandum of Understanding (MOU) with the Department of Health outlining the delegation of duties from the Department to the Office and as required by federal and state statutes.

 

R30-1-4. Office Duties.

(1) The Office of the Inspector General shall perform the following duties:

(a) The Office shall receive reports of suspected fraud, waste, or abuse in the state Medicaid program through phone, website, mail, or other electronic means open to the public:

(i) Establish a 24-hour, toll free hotline monitored by staff, or voicemail as appropriate.

(ii) Establish a separate identifiable email to report fraud, waste or abuse of Medicaid funds.

(b) The Office shall investigate and identify potential or actual fraud, waste, or abuse in the state Medicaid program by post payment review of claims paid under fee-for service, managed care, capitation, waiver, contracts or other payment methods where funds are expended by the Department of Health for Medicaid related services or programs.

(c) The Office shall establish an MOU with the Medicaid Fraud Control Unit to identify and recover improperly or fraudulently expended Medicaid funds.

(d) The Office shall determine appropriate methodology for identifying risk associated with the Department of Health and its programs under Medicaid funding.

(2) The Office shall regularly report to the Department regarding all identified cases of fraud, waste or abuse. The Office will report how the Department can reduce cost or improve performance through changes in policies or claims payment systems. The Office will operate the program integrity function and audit function to the extent possible and as described under a MOU with the Department

(3) The Office shall establish a means for providers to return payments to the Office. The Office will return all collected overpayments to the appropriate department.

(4) The Office shall afford any person or entity due process and administrative hearing rights through Subsection R414-1-5(16).

 

R30-1-5. Incorporations by Reference.

(1) All rules, regulations, and laws below are incorporated by reference.

 

R30-1-6. Medicaid Fraud (Criminal).

(1) The Office establishes and maintains methods, criteria, and procedures that meet all federal and state requirements for prevention of program fraud and abuse.

(2) The Office will enter into an MOU with The Medicaid Fraud Control Unit (MFCU) and the Department to ensure appropriate measures are established to reduce and prevent fraud and abuse in the Medicaid program.

(3) The Office shall report any instances of suspected Provider criminal fraud or misconduct to the MFCU within reasonable time.

(a) A hold shall be placed on the funds in accordance with 42 CFR 455.23.

(i) The Office shall notify the provider of the suspension within five (5) days; notice shall be given to the provider in accordance with Section R30-1-11a.

(ii) Law Enforcement may request in writing to delay notification of the provider in accordance with 42 CFR 455.23.

(4) The Office shall report instances of suspected recipient criminal fraud or misconduct in accordance with Subsection 63A-13-202(1)(k) to the appropriate law enforcement agency within a reasonable time.

 

R30-1-7a. Auditing of the State and Local Entities: Audit Responsibilities.

(1) Audit is defined as an independent, objective review of a process and associated controls to determine the effectiveness, efficiency and or compliance of that program or process.

Audits will be conducted under the regular supervision of the Inspector General.

(a) The specific definition of Audit, defined above, shall only apply to audits executed within the scope of Section R30-1-7a.

(2) The audit reports pertaining to the functioning of the Department will then be released to the Governor, Speaker of the House, President of the Senate, Executive Director of the Department that is audited.

(3) Audits will primarily be determined through a risk assessment approved by the Office.

(4) Audit activities of the Office will remain free of influence from any Department, Division, private or contracted entities.

(5) The Office audit group will follow the Generally Accepted Government AuditingStandards (GAGAS) Federal OIG Quality Standards by the Council of Inspectors General on Integrity and Efficiency (CIGIE) as it relates to audit standards, inspections and review standards.

(6) The auditors will immediately notify the Inspector General of any serious deficiency or the suspicion of significant fraud during its review.

(7) Pursuant to Section 63A-13-301 the Office will have unrestricted access to all records of state executive branch entities, all local government entities, and all providers relating directly or indirectly to the state Medicaid program.

 

R30-1-7b. Auditing of the State and Local Entities: Audit Plan.

(1) An audit plan will be prepared by the Office at least annually and shall:

(a) Identify the audits to be performed based on audit risk assessment reviewed annually;

(b) Identify resources to be devoted to audits in plan;

(c) Ensure that audits evaluate the efficiency and effectiveness of tax payer dollars in the Medicaid program;

(d) Determine adequacy of Medicaid's controls over federal and state compliance.

(2) The OIG audit function shall:

(a) Issue regular audit reports on the effectiveness and efficiency of the defined audits within the Medicaid program in Utah;

(b) Ensure that such audits are conducted within professional standards such as those defined by the Generally Accepted Governmental Auditing Standards (GAGAS), GIGIE QSI, or the Association of Inspector Generals;

(c) Report annually to the Governor's office on or before October 1, and to the Utah Legislature before November 30 as stated in Section 63A-13-502.

 

R30-1-8a. Auditing of Medical Providers.

(1) The Office may conduct performance and financial audits of entities described in Subsection 63A-13-202(2).

(2) Ensure that such audits are conducted within professional standards such as those defined by the Generally Accepted Governmental Auditing Standards (GAGAS), Federal Office of Inspector General, or the Association of Inspector Generals.

(3) The Office may conduct audits based upon risk assessments, random samples, and referrals from any credible source.

(4) The audit findings shall be reported to the audited entity within 30 days of the closing of the audit. The Office shall send a written report with the findings and recommendations.

(5) Each audit shall consider impact to the provider community when making recommendations to the Department and applying a remedy if necessary.

 

R30-1-8b. Access to Records and Employees.

(1) In order to fulfill the duties described in Section 63A-13-202, the Office shall have unrestricted access to all records of state executive branch entities, all local government entities, and all providers relating, directly or indirectly, as stated in 63A-13-301. Access to employees that the inspector general determines may assist in the fulfilling of the duties of the Office shall be granted as stated in Section 63A-13-302.

(2) The Office shall request access to records or documents through a written request. The responding agency or entity must respond to the request within 30 days.

(a) The written request shall be sent in accordance with R30-1-11-2.

 

R30-1-9. Subpoena Power.

(1) The Office shall have the power to issue a subpoena to obtain records or interview a person that the Office has the right to access as stated in 63A-13-401.

(2) The form of Subpoena shall meet the requirements of Utah Rule of Civil Procedure 45.

 

R30-1-10a. Post-Payment Review: Utilization Reviews and Medicaid Reviews of Services Provided Under the Utah Medicaid Program.

(1) The Office shall conduct hospital utilization reviews as outlined in the Department's Superior System Waiver in effect at the time service was rendered.

(2) The Office may request records that support provider claims for payment under programs funded through the Department.

(3) The medical records requests shall comply with Section R30-1-11b.

(4) The Office shall review the records in accordance with Department rules and policies in effect at the time the service was rendered.

(i) The Office shall enforce policies in accordance with Subsections 63A-13-202(3)(a) - (b).

 

R30-1-10b. Post-Payment Review: Thirty Day Re-Admissions.

(1) The Office shall conduct reviews of hospital re-admissions within 30 days. The reviews shall be conducted in accordance with the Department's Superior System Waiver in effect at the time service was rendered.

(2) The Office may request records to evaluate the re-admissions.

(3) The medical records requests shall comply with Section R30-1-11b.

(4) If after review of the re-admission and the claim or encounter does not comply with the Department's policy the Office shall appropriately enforce the Department's policy and or rule.

 

R30-1-10c. Post-Payment Review: Medicaid Program Integrity (MPI).

(1) The Office shall conduct post-payment review of claims submitted by providers to Medicaid.

(2) The Office shall investigate of any referral that contains allegations of fraud, waste and abuse in accordance with 42 CFR 455.

(3) The Office shall conduct post-payment review of the claims for fraud, waste and abuse.

(4) The Office may request medical records to evaluate the claims.

(5) The medical records requests shall comply with Section R30-1-11b.

(6) If after review, the claim submitted does not comply with the Department Health policy, the Office shall appropriately enforce Department Health policy and or rule.

(7) The Office shall enforce policies in accordance with Subsections 63A-13-202(3)(a) - (b).

 

R30-1-10d. Post-Payment Review: Site Visits.

(1) The Office of Inspector General shall conduct site visits in a minimally intrusive manner. The Office shall perform the following prior to a site visit:

(a) The Office shall notify the provider of a site visit in writing, seven (7) calendar days before the inspection. The notice requirement shall comply with Section R30-1-11a.

(b) The Office shall make reasonable efforts to coordinate and afford the provider an opportunity to make an appointment and arrange visits at a time best suited for the provider.

(c) The Office shall attempt to minimize interference with patient care.

(2) If there is a credible allegation of fraud, the requirements of Section R30-1-12(1) are not required.

(3) This rule does not limit the Office from conducting new Provider Enrollment site visits under 42 CFR 455.432.

(a) Provider Enrollment visits shall be conducted in a minimally intrusive manner, during normal business hours.

(b) No notice is required for Provider Enrollment site visits, if it is a verification visit.

 

R30-1-10e. Post-Payment Review: Training.

(1) The Office of Inspector General shall provide training to the provider community at no cost.

(2) The training may include the following:

(a) Common methods to prevent fraud, waste and abuse.

(b) Current trends on how fraud, waste and abuse are occurring.

(c) How to report fraud, waste, and abuse.

(d) Office programs and audit policies, procedures, and compliance.

(e) Any other topic necessary to carry out the duties of the Office.

(3) The Office may conduct quarterly webinars on topics that pertain to Medicaid.

(4) The Office may consult with the Department to prepare curriculum and training material.

(5) Any provider may request training by contacting the Office.

 

R30-1-10f. Post-Payment Review: Policy Reviews.

(1) The Office shall conduct policy reviews of the Medicaid Provider Manuals and the Medicaid information bulletins (MIBs). These reviews shall be conducted as follows:

(a) The Office shall review the policies for internal inconsistencies and report those to the Department.

(b) The Office shall complete the review within 45 days from receiving the proposed policy from the Department.

(c) The Office shall advise and make recommendations on the policy if there is a policy that would create waste or abuse in the Medicaid program.

(d) Recommendations may be submitted to the Department for review.

(e) This procedure shall occur prior to the publishing of the MIB and policies.

 

R30-1-11a. Provider Communication: Notices of Recovery.

(1) The Office shall notify providers of overpayments and recover improperly paid claims through the following:

(a) Any suspected recoupment or take back against future funds less than $5,000 shall be communicated to the provider via first class mail including a verification certificate attached to verify delivery.

(b) Any suspected recoupment or take back against future funds greater than $5,000 shall be communicated to the provider through certified mail or similar guaranteed delivery mechanism.

(c) Administrative hearing notice requirements will also comply with (a) and (b) above.

(d) Notices of suspension of payments and placement of holds will also comply with (a) and (b) above.

(d) In addition to the methods set forth in this rule, a party may be served as permitted by the Utah Rules of Civil Procedure.

(2) The Office shall send the notice of recovery to the mailing address that is on file with the Department of Health. The Provider may, request in writing, that the Office use the billing address or the service location address on file with the Department of Health. The written request to the Office shall specify the address to be used, the address identified by the Provider must be on file with the Department of Health, the OIG shall not send correspondence to an address not on file with the Department of Health.

 

R30-1-11b. Provider Communication: Records Requests.

(1) The Office may request records that support provider claims for payment under programs funded through the Department of Health. These requests shall be in writing and identify the records to be reviewed.

(2) The requests shall be sent first class mail with proper United States Postal Service postage attached; to the mailing address on file with the Department of Health.

(i) If a request is returned undeliverable the Office shall send the notification of an invalid address to the Department of Health.

(ii) The Office shall file a certificate of service that certifies the request was sent that contain the following requirements:

(a) The date of mailing.

(b) The name of the sender.

(c) The signature, electronic or otherwise, of the sender that verifies the document was properly mailed.

(d) Address that the records request was sent to.

(e) Written responses to requests shall be returned within 30 days of the date of the written request. Responses must include the complete record of all services and supporting services for which reimbursement is claimed.

(f) However, if there is no response within the 30 day period, the Office shall close the record and shall evaluate the payment based on the records that the Office has in its file.

(3) The Office shall send the requests for records to the mailing address that is on file with the Department of Health. The Provider may, requests in writing, that the Office use the billing address or the service location address on file with the Department of Health. The written request to the Office shall specify the address to be used, the address identified by the Provider must be on file with the Department of Health, the OIG shall not send correspondence to an address not on file with the Department of Health.

(4) The Office shall limit requests for medical records to 36 months prior to the date of the inception of the investigation in accordance with Section 63A-13-204.

 

R30-1-12. Placement of Hold.

(1) The Office shall notify the provider of any hold on payment through written correspondence with in five (5) days. The correspondence shall be communicated to the provider in a manner consistent with Section R30-1-11a.

(2) The correspondence shall contain the following:

(a) Name and address of provider.

(b) Notification of suspension.

(c) General reason for suspension.

(d) Explanation of due process rights.

(3) Providers may request a state fair hearing through Subsection R414-1-5(16) Office of Inspector General Administrative Hearings Procedures Manual.

 

R30-1-13. Human Resources.

(1) The Office incorporates by reference the DHRM rules under Title R477 applicable to the type and category of the employees in the Office.

(2) The Office incorporated by reference the OIG Human Resources Manual and Policies.

 

R30-1-14. General Rule Format.

(1) The following format is used generally throughout the rules of the Office. Section headings as indicated and the following general definitions are for guidance only. The section headings are not part of the rule content itself. In certain instances, this format may not be appropriate and will not be implemented due to the nature of the subject matter of a specific rule.

(2) Introduction and Authority. A concise statement as to what Medicaid service is covered by the rule, and a listing of specific federal statutes and regulations and state statutes that authorize or require the rule.

(3) Definitions. Definitions that have special meaning to the particular rule.

(4) Other Sections. As necessary under the particular rule, additional sections may be indicated. Other sections include regulatory language that does not fit into sections (1) through (4).

 

KEY: Office of the Inspector General, Medicaid fraud, Medicaid waste, Medicaid abuse

Date of Enactment or Last Substantive Amendment: 2013

Authorizing, and Implemented or Interpreted Law: 63A-13-101 to 602

 

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