MISSISSIPPI LEGISLATURE
2013 Regular Session
To: Medicaid
By: Representative Flaggs
AN ACT TO REQUIRE THE DIVISION OF MEDICAID TO IMPLEMENT STATE-OF-THE ART CLINICAL CODE EDITING TECHNOLOGY IN THE AREA OF CORRECTIONAL HEALTH CARE; TO REQUIRE MEDICAID TO IMPLEMENT CORRECTIONAL HEALTH CARE CLAIMS AUDIT AND RECOVERY SERVICES TO IDENTIFY CERTAIN IMPROPER PAYMENTS; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. The Legislature finds that states have saved millions of dollars by implementing solutions to eliminate and recover correctional health care overpayments. Similarly, states have significantly reduced correctional health care costs by billing Medicaid for eligible inpatient costs. Therefore, it is the intent of the Legislature to implement automated payment detection, prevention and recovery solutions to reduce correctional health care overpayments and to assure that Medicaid is billed for eligible inpatient hospital and professional services.
SECTION 2. Unless otherwise stated, this act shall specifically apply to:
(a) State correctional health care systems and services; and
(b) State contracted managed correctional health care services.
SECTION 3. The Division of Medicaid shall implement state-of-the art clinical code editing technology solutions to further automate claims resolution and enhance cost containment through improved claim accuracy and appropriate code correction. The technology shall identify and prevent errors or potential overbilling based on widely accepted and referenceable protocols such as the American Medical Association and the Centers for Medicare and Medicaid Services. The clinical code editing technology shall be applied automatically before claims are adjudicated to speed processing and reduce the number of pending or rejected claims and help ensure a smoother, more consistent and more open adjudication process and fewer delays in provider reimbursement.
SECTION 4. The Division of Medicaid shall implement correctional health care claims audit and recovery services to identify improper payments due to nonfraudulent issues, audit claims, obtain provider sign-off on the audit results and recover validated overpayments. Post payment reviews shall ensure the diagnoses and procedure codes are accurate and valid based on the supporting physician documentation within medical records. Core categories of reviews may include, but are not limited to, the following:
(a) Coding Compliance Diagnosis Related Group (DRG) Reviews;
(b) Transfers;
(c) Readmissions;
(d) Cost outlier reviews;
(e) Outpatient 72-Hour Rule Reviews;
(f) Payment errors; and
(g) Billing errors.
SECTION 5. The Division of Medicaid shall implement automated payment detection, prevention and recovery solutions to assure that Medicaid is billed for eligible inpatient hospital and professional services.
SECTION 6. It is the intent of the Legislature that the Division of Medicaid shall contract for correctional health care audit and recovery services and that the savings achieved through this act shall more than cover the cost of implementation and administration. To the extent possible, technology services used in carrying out this act shall 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, reimbursement to the contractor may be contracted on the basis of a percentage of an 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 prescribed under this section. Reimbursement models with the contractor may also include performance guarantees of the contractor to ensure savings identified exceeds program costs.
SECTION 7. This act shall take effect and be in force from and after July 1, 2013.