97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
HB4118

 

Introduced , by Rep. Sara Feigenholtz

 

SYNOPSIS AS INTRODUCED:
 
New Act

    Creates the Program Integrity for Medicaid and the Children's Health Insurance Program Act. Provides that it is the intent of the General Assembly to implement waste, fraud, and abuse detection, prevention, and recovery solutions to improve program integrity for Medicaid and the Children's Health Insurance Program in the State and create efficiency and cost savings through a shift from a retrospective "pay and chase" model to a prospective pre-payment model; and to comply with program integrity provisions of the federal Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010. In furtherance of these goals, requires the State to implement several technologies and services including (i) provider data verification and provider screening technology; (ii) state-of-the-art clinical code editing technology; (iii) state-of-the-art predictive modeling and analytics technologies; (iv) fraud investigative services; and (v) Medicaid and CHIP claims audit and recovery services. Requires the State to either contract with The Cooperative Purchasing Network (TCPN) to issue a request for proposals (RFP) when selecting a contractor or use the specified contractor selection process. Contains provisions concerning contracts, reporting requirements, and savings.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This Act may be cited as the
5Program Integrity for Medicaid and the Children's Health
6Insurance Program Act.
 
7    Section 5. Purpose. It is the intent of the General
8Assembly to implement waste, fraud, and abuse detection,
9prevention, and recovery solutions to:
10        (1) improve program integrity for Medicaid and the
11    Children's Health Insurance Program in the State and create
12    efficiency and cost savings through a shift from a
13    retrospective "pay and chase" model to a prospective
14    pre-payment model; and
15        (2) comply with program integrity provisions of the
16    federal Patient Protection and Affordable Care Act and the
17    Health Care and Education Reconciliation Act of 2010, as
18    promulgated in the Centers for Medicare and Medicaid
19    Services Final Rule 6028.
 
20    Section 10. Definitions. As used in this Act, unless the
21context indicates otherwise:
22    "Medicaid" means the program to provide grants to states

 

 

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1for medical assistance programs established under Title XIX of
2the Social Security Act (42 U.S.C. 1396 et seq.).
3    "CHIP" means the Children's Health Insurance Program
4established under Title XXI of the Social Security Act (42
5U.S.C. 1397aa et seq.).
6    "Enrollee" means an individual who is eligible to receive
7benefits and is enrolled in either Medicaid or CHIP.
8    "Secretary" means the U.S. Secretary of Health and Human
9Services, acting through the Administrator of the Centers for
10Medicare and Medicaid Services.
 
11    Section 15. Application of Act. This Act shall specifically
12apply to:
13        (1) State Medicaid managed care programs operated
14    under Article V of the Illinois Public Aid Code.
15        (2) State Medicaid programs operated under Article V of
16    the Illinois Public Aid Code.
17        (3) The State CHIP program operated under the
18    Children's Health Insurance Program Act.
 
19    Section 20. Provider data verification and provider
20screening technology. The State shall implement provider data
21verification and provider screening technology solutions to
22check healthcare billing and provider rendering data against a
23continually maintained provider information database for the
24purposes of automating reviews and identifying and preventing

 

 

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1inappropriate payments to:
2        (1) Deceased providers.
3        (2) Sanctioned providers.
4        (3) License expiration or retired providers.
5        (4) Confirmed wrong addresses.
 
6    Section 25. Clinical code editing technology. The State
7shall implement state-of-the-art clinical code editing
8technology solutions to further automate claims resolution and
9enhance cost containment through improved claim accuracy and
10appropriate code correction. The technology shall identify and
11prevent errors or potential over-billing based on widely
12accepted and transparent protocols such as those adopted by the
13American Medical Association and the Centers for Medicare and
14Medicaid Services. The edits shall be applied automatically
15before claims are adjudicated to speed processing and reduce
16the number of pending or rejected claims and to help ensure a
17smoother, more consistent, and more transparent adjudication
18process and fewer delays in provider reimbursement.
 
19    Section 30. Predictive modeling and analytics
20technologies. The State shall implement state-of-the-art
21predictive modeling and analytics technologies to provide a
22more comprehensive and accurate view across all providers,
23beneficiaries, and geographies within the Medicaid and CHIP
24programs in order to:

 

 

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1        (1) Identify and analyze those billing or utilization
2    patterns that represent a high risk of fraudulent activity.
3        (2) Be integrated into the existing Medicaid and CHIP
4    claims workflow.
5        (3) Undertake and automate such analysis before
6    payment is made to minimize disruptions to the workflow and
7    speed claim resolution.
8        (4) Prioritize such identified transactions for
9    additional review before payment is made based on
10    likelihood of potential waste, fraud, or abuse.
11        (5) Capture outcome information from adjudicated
12    claims to allow for refinement and enhancement of the
13    predictive analytics technologies based on historical data
14    and algorithms within the system.
15        (6) Prevent the payment of claims for reimbursement
16    that have been identified as potentially wasteful,
17    fraudulent, or abusive until the claims have been
18    automatically verified as valid.
 
19    Section 35. Fraud investigative services. The State shall
20implement fraud investigative services that combine
21retrospective claims analysis and prospective waste, fraud, or
22abuse detection techniques. These services shall include
23analysis of historical claims data, medical records, suspect
24provider databases, and high-risk identification lists, as
25well as direct patient and provider interviews. Emphasis shall

 

 

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1be placed on providing education to providers and ensuring that
2they have the opportunity to review and correct any problems
3identified prior to adjudication.
 
4    Section 40. Claims audit and recovery services. The State
5shall implement Medicaid and CHIP claims audit and recovery
6services to identify improper payments due to non-fraudulent
7issues or audit claims and shall obtain provider sign-off on
8the audit results and recover validated overpayments.
9Post-payment reviews shall ensure that the diagnoses and
10procedure codes are accurate and valid based on the supporting
11physician documentation within the medical records. Core
12categories of reviews may include: Coding Compliance Diagnosis
13Related Group (DRG) Reviews, Transfers, Readmissions, Cost
14Outlier Reviews, Outpatient 72-Hour Rule Reviews, Payment
15Errors, Billing Errors, and others.
 
16    Section 45. Cooperative Purchasing Network.
17    (a) To implement this Act, the State shall either contract
18with The Cooperative Purchasing Network (TCPN) to issue a
19request for proposals (RFP) when selecting a contractor or use
20the contractor selection process set forth in subsections (b)
21through (f).
22    (b) Not later than November 1, 2012, the State shall issue
23a request for information (RFI) to seek input from potential
24contractors on capabilities and cost structures associated

 

 

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1with the scope of work under this Act. The results of the RFI
2shall be used by the State to create a formal RFP to be issued
3within 90 days after the closing date of the RFI.
4    (c) No later than 90 days after the closing date of the
5RFI, the State shall issue a formal RFP to carry out this Act
6during the first year of implementation. To the extent
7appropriate, the State may include subsequent implementation
8years and may issue additional RFPs with respect to subsequent
9implementation years.
10    (d) The State shall select contractors to carry out this
11Act using competitive procedures set forth under the Illinois
12Procurement Code.
13    (e) The State shall enter into a contract under this Act
14with an entity only if the entity:
15        (1) can demonstrate appropriate technical, analytical,
16    and clinical knowledge and experience to carry out the
17    functions included under this Act; or
18        (2) has a contract, or will enter into a contract, with
19    another entity that meets the criteria set forth in
20    paragraph (1).
21    (f) The State shall enter into a contract under this Act
22with an entity only to the extent the entity complies with
23conflict-of-interest standards as provided under the Illinois
24Procurement Code.
 
25    Section 50. Contracts. The State shall provide an entity

 

 

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1with whom it has entered into a contract under this Act with
2appropriate access to claims and other data necessary for the
3entity to carry out the functions included in this Act. This
4includes, but is not limited to, providing current and
5historical Medicaid and CHIP claims and provider database
6information and taking necessary regulatory action to
7facilitate appropriate public-private data sharing, including
8across multiple Medicaid managed care entities.
 
9    Section 55. Reports.
10    (a) The Department of Healthcare and Family Services shall
11complete reports as set forth in subsections (b) through (d).
12    (b) Not later than 3 months after the completion of the
13first implementation year under this Act, the State shall
14submit to the appropriate committees of the General Assembly
15and make available to the public a report that includes the
16following:
17        (1) A description of the implementation and use of
18    technologies included in this Act during the year.
19        (2) A certification by the Department of Healthcare and
20    Family Services that specifies the actual and projected
21    savings to the Medicaid and CHIP programs as a result of
22    the use of these technologies, including estimates of the
23    amounts of such savings with respect to both improper
24    payments recovered and improper payments avoided.
25        (3) The actual and projected savings to the Medicaid

 

 

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1    and CHIP programs as a result of the use of these
2    technologies relative to the return on investment for the
3    use of these technologies and in comparison to other
4    strategies or technologies used to prevent and detect
5    fraud, waste, and abuse.
6        (4) Any modifications or refinements that should be
7    made to increase the amount of actual or projected savings
8    or mitigate any adverse impact on Medicare beneficiaries or
9    providers.
10        (5) An analysis of the extent to which the use of these
11    technologies successfully prevented and detected waste,
12    fraud, or abuse in the Medicaid and CHIP programs.
13        (6) A review of whether the technologies affected
14    access to, or the quality of, items and services furnished
15    to Medicaid and CHIP beneficiaries.
16        (7) A review of what effect, if any, the use of these
17    technologies had on Medicaid and CHIP providers, including
18    assessment of provider education efforts and documentation
19    of processes for providers to review and correct problems
20    that are identified.
21    (c) Not later than 3 months after the completion of the
22second implementation year under this Act, the State shall
23submit to the appropriate committees of the General Assembly
24and make available to the public a report that includes, with
25respect to such year, the items required under subsection (b)
26as well as any other additional items determined appropriate

 

 

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1with respect to the report for such year.
2    (d) Not later than 3 months after the completion of the
3third implementation year under this Act, the State shall
4submit to the appropriate committees of the General Assembly,
5and make available to the public, a report that includes, with
6respect to such year, the items required under subsection (b)
7as well as any other additional items determined appropriate
8with respect to the report for such year.
 
9    Section 60. Savings. It is the intent of the General
10Assembly that the savings achieved through this Act shall more
11than cover the costs of implementation. Therefore, to the
12extent possible, technology services used in carrying out this
13Act shall be secured using a shared savings model, whereby the
14State's only direct cost will be a percentage of actual savings
15achieved. Further, to enable this model, a percentage of
16achieved savings may be used to fund expenditures under this
17Act.
 
18    Section 97. Severability. If any provision of this Act or
19its application to any person or circumstance is held invalid,
20the invalidity of that provision or application does not affect
21other provisions or applications of this Act that can be given
22effect without the invalid provision or application.