HB2417: Prepayment analytics; DMAS shall establish program relating to fraud prevention.
Be it enacted by the General Assembly of Virginia:
1. That § 2.2-4348 of the Code of Virginia is amended and reenacted and that the Code of Virginia is amended by adding a section numbered 32.1-319.1 as follows:
§ 2.2-4348. Exemptions.
The provisions of this article shall not apply to (i) the late payment provisions contained in any public utility tariffs prescribed by the State Corporation Commission or (ii) payments for services provided under the state plan for medical assistance identified as potentially fraudulent, abusive, or erroneous in accordance with the program established pursuant to § 32.1-319.1 and delayed until such time as the claim can be validated.
§ 32.1-319.1. Department to establish program to use prepayment analytics to mitigate risk of improper payments.
A. The Department shall establish a program using prepayment analytics to mitigate the risk of improper payments to providers of services that are paid through the Department's fee-for-service delivery system who commit fraud, abuse, or errors. Such program shall include the use of predictive modeling, provider profiling, trend analysis, and other prepayment analytics to identify providers and claims with a high likelihood of fraud, abuse, or error and prevent payments on potentially fraudulent claims from being made until such claims have been validated.
B. The Department may enter into a contract or agreement with a vendor for the operation of the program to mitigate risk of improper payments to providers of services that are paid through the Department's fee-for-service delivery system required by this section.
2. That the provisions of this act shall not become effective unless an appropriation effectuating the purposes of this act is included in a general appropriation act passed in 2017 by the General Assembly that becomes law.
Be it enacted by the General Assembly of Virginia:
1. That § 2.2-4348 of the Code of Virginia is amended and reenacted and that the Code of Virginia is amended by adding a section numbered 32.1-319.1 as follows:
§ 2.2-4348. Exemptions.
The provisions of this article shall not apply to (i) the late payment provisions contained in any public utility tariffs prescribed by the State Corporation Commission or (ii) payments for services provided under the state plan for medical assistance identified as potentially fraudulent, abusive, or erroneous in accordance with the program established pursuant to § 32.1-319.1 and delayed until such time as the claim can be validated.
§ 32.1-319.1. Department to establish program [ to use prepayment analytics ] to mitigate risk of improper payments.
A. The Department shall establish a program [ using
prepayment analytics ] to mitigate the risk of improper payments to
providers of services [ furnished under the state plan for medical
assistance that are paid through the Department's fee-for-service
delivery system ] who commit fraud, abuse, or errors. Such program shall
include the use of predictive modeling, provider profiling, trend analysis, and
other prepayment analytics to identify providers [ and claims ] with
a high likelihood of fraud, abuse, or error and prevent payments on potentially
fraudulent claims from being made until such claims have been validated.
B. The Department may enter into a contract or agreement
with a vendor for the operation of the program to mitigate risk of improper
payments to providers of services [ furnished under the state plan
for medical assistance that are paid through the Department's
fee-for-service delivery system ] required by this section.
HOUSE BILL NO. 2417
Be it enacted by the General Assembly of Virginia:
1. That § 2.2-4348 of the Code of Virginia is amended and reenacted and that the Code of Virginia is amended by adding a section numbered 32.1-319.1 as follows:
§ 2.2-4348. Exemptions.
The provisions of this article shall not apply to (i) the late payment provisions contained in any public utility tariffs prescribed by the State Corporation Commission or (ii) payments for services provided under the state plan for medical assistance identified as potentially fraudulent, abusive, or erroneous in accordance with the program established pursuant to § 32.1-319.1 and delayed until such time as the claim can be validated.
§ 32.1-319.1. Department to establish program to mitigate risk of improper payments.
A. The Department shall establish a program to mitigate the risk of improper payments to providers of services furnished under the state plan for medical assistance who commit fraud, abuse, or errors. Such program shall include the use of predictive modeling, provider profiling, trend analysis, and other prepayment analytics to identify providers with a high likelihood of fraud, abuse, or error and prevent payments on potentially fraudulent claims from being made until such claims have been validated.
B. The Department may enter into a contract or agreement with a vendor for the operation of the program to mitigate risk of improper payments to providers of services furnished under the state plan for medical assistance required by this section.