205.6318 Cabinet to establish integrated system to enhance program integrity of Medical Assistance Program. - Kentucky Statutes

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Page 1 of 1 205.6318 Cabinet to establish integrated system to enhance program integrity of 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. Effective: June 20, 2005
History: Amended 2005 Ky. Acts ch. 99, sec. 251, effective June 20, 2005. -- Amended 2000 Ky. Acts ch. 14, sec. 33, effective July 14, 2000. -- Amended 1998 Ky. Acts
ch. 426, sec. 209, effective July 15, 1998. -- Created 1994 Ky. Acts ch. 512, sec. 76,
effective July 15, 1994.