Passed by the House February 13, 2012 Yeas 96   ________________________________________ Speaker of the House of Representatives Passed by the Senate March 8, 2012 Yeas 49   ________________________________________ President of the Senate | I, Barbara Baker, Chief Clerk of the House of Representatives of the State of Washington, do hereby certify that the attached is ENGROSSED SUBSTITUTE HOUSE BILL 2571 as passed by the House of Representatives and the Senate on the dates hereon set forth. ________________________________________ Chief Clerk | |
Approved ________________________________________ Governor of the State of Washington | Secretary of State State of Washington |
State of Washington | 62nd Legislature | 2012 Regular Session |
READ FIRST TIME 02/06/12.
AN ACT Relating to waste, fraud, and abuse prevention, detection, and recovery to improve program integrity for medical services programs; adding a new chapter to Title 74 RCW; and providing an effective date.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
NEW SECTION. Sec. 1 It is the intent of the legislature to:
(1) Implement waste, fraud, and abuse detection, prevention, and
recovery solutions to improve program integrity for medical services
programs in the state 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 or strategies
that yield the highest return on investment.
NEW SECTION. Sec. 2 The definitions in this section apply
throughout this chapter unless the context clearly requires otherwise.
(1) "Authority" means the Washington state health care authority.
(2) "Enrollee" means an individual who receives benefits through a
medical services program.
(3) "Medical services programs" means those medical programs
established under chapter 74.09 RCW, including medical assistance, the
limited casualty program, children's health program, medical care
services, and state children's health insurance program.
NEW SECTION. Sec. 3 (1) Not later than September 1, 2012, the
authority shall issue a request for information to seek input from
potential contractors on capabilities that the authority does not
currently possess, functions that the authority is not currently
performing, and the cost structures associated with implementing:
(a) Advanced predictive modeling and analytics technologies to
provide a comprehensive and accurate view across all providers,
enrollees, and geographic locations within the medical services
programs in order to:
(i) Identify and analyze those billing or utilization patterns that
represent a high risk of fraudulent activity;
(ii) Be integrated into the existing medical services programs
claims operations;
(iii) Undertake and automate such analysis before payment is made
to minimize disruptions to agency operations and speed claim
resolution;
(iv) Prioritize such identified transactions for additional review
before payment is made based on the likelihood of potential waste,
fraud, or abuse;
(v) Obtain outcome information from adjudicated claims to allow for
refinement and enhancement of the predictive analytics technologies
based on historical data and algorithms with the system;
(vi) 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 enrollee data verification and screening
technology solutions, which may use publicly available records, for the
purposes of automating reviews and identifying and preventing
inappropriate payments by:
(i) Identifying associations between providers, practitioners, and
beneficiaries which indicate rings of collusive fraudulent activity;
and
(ii) Discovering enrollee attributes which indicate improper
eligibility, including, but not limited to, death, out-of-state
residence, inappropriate asset ownership, or incarceration; and
(c) Fraud investigation services that combine retrospective claims
analysis and prospective waste, fraud, or abuse detection techniques.
These services must include analysis of historical claims data, medical
records, suspect provider databases, and high-risk identification
lists, as well as direct enrollee and provider interviews. Emphasis
must be placed on providing education to providers and allowing them
the opportunity to review and correct any problems identified prior to
adjudication.
(2) The authority is encouraged to use the results of the request
for information to create a formal request for proposals to carry out
the work identified in this section if the following conditions are
met:
(a) The authority expects to generate state savings by preventing
fraud, waste, and abuse;
(b) This work can be integrated into the authority's current
medical services claims operations without creating additional costs to
the state;
(c) The reviews or audits are not anticipated to delay or
improperly deny the payment of legitimate claims to providers.
NEW SECTION. Sec. 4 It is the intent of the legislature that the
savings achieved through this chapter shall more than cover the cost of
implementation and administration. Therefore, to the extent possible,
technology services used in carrying out this chapter must be secured
using the savings generated by the program, whereby the state's only
direct cost will be funded through the actual savings achieved.
Further, to enable this model, reimbursement to the contractor may be
contracted on the basis of a percentage of achieved savings model, a
per beneficiary per month model, a per transaction model, a case-rate
model, or any blended model of the aforementioned methodologies.
Reimbursement models with the contractor may include performance
guarantees of the contractor to ensure savings identified exceeds
program costs.
NEW SECTION. Sec. 5 Sections 1 through 4 of this act constitute
a new chapter in Title
NEW SECTION. Sec. 6 If any provision of this act or its
application to any person or circumstance is held invalid, the
remainder of the act or the application of the provision to other
persons or circumstances is not affected.
NEW SECTION. Sec. 7 This act takes effect July 1, 2012.