205.6318 Cabinet to establish integrated system to enhance program integrity of

349 words·~2 min read·/ky/205-6318

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Medical Assistance Program. The Cabinet for Health and Family Services shall review the available technology associated with the medical assistance system to determine which technology is best suited to enhance program service operation, monitoring ability, and fraud and abuse detection. This shall include the ability to provide on-line access to data files to allow cross-analysis of provider and recipient utilization patterns. The cabinet shall by promulgation of administrative regulations, pursuant to KRS Chapter 13A, establish an integrated system to enhance program integrity, using a combination of staff, computer technology, and contractual services to identify potential fraud, abuse, and misutilization of services.

This system shall:

(1)Utilize statisticians, program specialists, accountants, nurses, and other medical

specialists to review the Medical Assistance Program to identify patterns of

provider and recipient behavior that contributes to unnecessary or abusive use of

program services;

(2)Utilize computer capability through contractual services or the purchase of

computer software to detect the unbundling of claims and other techniques used by

providers to enhance reimbursement;

(3)Impose utilization controls on the expenditures in respiratory, physical, speech, and

occupational therapy and durable medical equipment provided to nursing-home

residents, through the use of established medical criteria or preauthorization of

ancillary therapies;

(4)Establish state audit and edit requirements that exceed the federal audit and edit

requirements;

(5)Obtain access to necessary data from the fiscal agent of each medical provider;

(6)Review the efficiency and effectiveness of the fraud and abuse detection and

investigation process to determine whether changes shall be made;

(7)Direct that fraud and abuse detection and investigation components shall be active

in initiating investigations. The fraud and abuse detection, investigation, and

prosecution functions shall be integrated, with access to information in files

maintained by the Department for Community Based Services and the Department

for Medicaid Services;

(8)Review penalties for deterrent value for medical providers that are found to have

abused Medicaid regulations and statutes; and

(9)Provide for a proactive effort to reduce costs for institutionalized program

participants. Program officials shall seek to implement innovative or experimental

demonstration programs that aim to control costs.