2012 -- S 2090

=======

LC00558

=======

STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2012

____________

A N A C T

RELATING TO HEATH AND SAFETY -- CORRECTIONAL HEALTHCARE ACT

     

     

     Introduced By: Senator William A. Walaska

     Date Introduced: January 18, 2012

     Referred To: Senate Finance

It is enacted by the General Assembly as follows:

1-1

     SECTION 1. Title 23 of the General Laws entitled "HEALTH AND SAFETY" is hereby

1-2

amended by adding thereto the following chapter:

1-3

     CHAPTER 87

1-4

CORRECTIONAL HEALTHCARE ACT

1-5

     23-87-1. Short title. – This chapter shall be known and may be cited as the “Correctional

1-6

Healthcare Act.”

1-7

     23-87-2. Legislative intent. -- It is the intent of the general assembly to:

1-8

     (1) Reduce the state’s correctional healthcare costs by requiring hospitals and other

1-9

medical service providers to bill Medicaid for eligible inmate inpatient hospital and professional

1-10

services;

1-11

     (2) Implement improper payment detection, prevention and recovery solutions to reduce

1-12

correctional healthcare costs by introducing prospective solutions to eliminate overpayments and

1-13

retrospective solutions to recover those overpayments that have already occurred;

1-14

     (3) Cap all contract and non-contract correctional healthcare reimbursement rates at no

1-15

more than one hundred ten percent (110%) of Medicare; and

1-16

     (4) Embrace technologies to better manage correctional healthcare expenses.

1-17

     23-87-3. Definitions. -- The following definition shall apply throughout this chapter

1-18

unless the context clearly requires otherwise:

1-19

     (1) “Medicare” means the social insurance program administered by the United States

1-20

government, established under Title XVIII of the Social Security Act of 1965.

2-1

     23-87-4. Application. -- Unless otherwise stated, this chapter shall specifically apply to:

2-2

     (1) State correctional healthcare systems and services provided under the general laws;

2-3

and

2-4

     (2) State contracted managed correctional healthcare services provided under the general

2-5

laws.

2-6

     23-87-5. Cap of payments. -- The state shall cap all contract and non-contract payments

2-7

to correctional healthcare providers at no more than one hundred ten percent (110%) of the

2-8

federal Medicare reimbursement rate.

2-9

     23-87-6. Electronic format. -- To the maximum extent practicable, all non-contract

2-10

correctional healthcare claims shall be submitted to the state in an electronic format.

2-11

     23-87-7. Billing for eligible services. -- Hospitals and other medical service providers

2-12

shall bill Medicaid for all eligible inmate inpatient hospital and professional services.

2-13

     23-87-8. Technology solutions. -- The state shall implement state-of-the-art clinical code

2-14

editing technology solutions to further automate claims resolution and enhance cost containment

2-15

through improved claim accuracy and appropriate code correction. The technology shall identify

2-16

and prevent errors or potential overbilling based on widely accepted and referenceable protocols

2-17

such as the American Medical Association and the Centers for Medicare and Medicaid Services.

2-18

The edits shall be applied automatically before claims are adjudicated to speed processing and

2-19

reduce the number of pending or rejected claims and help ensure a smoother, more consistent and

2-20

more open adjudication process and fewer delays in provider reimbursement.

2-21

     23-87-9. Predictive modeling technology. -- The state shall implement state-of-the-art

2-22

predictive modeling and analytics technologies to provide a more comprehensive and accurate

2-23

view across all providers, beneficiaries and geographies within correctional healthcare programs

2-24

in order to:

2-25

     (1) Assure that hospitals and medical service providers bill Medicaid for all eligible

2-26

inmate inpatient hospital and professional services;

2-27

     (2) Identify and analyze those billing or utilization patterns that represent a high risk of

2-28

inappropriate, inaccurate or erroneous activity;

2-29

     (3) Undertake and automate such analysis before payment is made to minimize

2-30

disruptions to the workflow and speed claim resolution;

2-31

     (4) Prioritize such identified transactions for additional review before payment is made

2-32

based on the likelihood of potentially inappropriate, inaccurate or erroneous activity;

2-33

     (5) Capture outcome information from adjudicated claims to allow for refinement and

2-34

enhancement of the predictive analytics technologies based on historical data and algorithms

3-1

within the system;

3-2

     (6) Prevent the payment of claims for reimbursement that have been identified as

3-3

potentially inappropriate, inaccurate or erroneous until the claims have been automatically

3-4

verified as valid; and

3-5

     (7) Audit and recover improper payments made to providers based upon inappropriate,

3-6

inaccurate or erroneous billing or payment activity.

3-7

     23-87-10. Audit and recover services. -- The state shall implement correctional

3-8

healthcare claims audit and recovery services to identify improper payments due to non-

3-9

fraudulent issues, audit claims, obtain provider sign-off on the audit results and recover validated

3-10

overpayments. Post payment reviews shall ensure that the diagnoses and procedure codes are

3-11

accurate and valid based on the supporting physician documentation within the medical records.

3-12

Core categories of reviews may include, without limitation: coding compliance diagnosis related

3-13

group (DRG) reviews, transfers, readmissions, cost outlier reviews, outpatient seventy-two (72)

3-14

hour rule reviews, payment errors, and billing errors and others.

3-15

     23-87-11. Contractor selection. -- To implement the inappropriate, inaccurate or

3-16

erroneous detection, prevention and recovery solutions in this chapter, the state shall either sign

3-17

an intergovernmental agreement with another state already receiving these services, contract with

3-18

the cooperative purchasing network (TCPN) to issue a request for proposals (RFP) to select a

3-19

contractor or use the following contractor selection process:

3-20

     (1) Not later than sixty (60) days after the effective date of this chapter the state shall

3-21

issue a request for information (RFI) to seek input from potential contractors on capabilities and

3-22

cost structures associated with the scope of work of this chapter. The results of the RFI shall be

3-23

used by the state to create a formal (RFP) to be issued within ninety (90) days of the closing date

3-24

of the RFI.

3-25

     (2) Not later than ninety (90) days after the close of the RFI, the state shall issue a formal

3-26

RFP to carry out this chapter during the first year of implementation. To the extent appropriate,

3-27

the state may include subsequent implementation years and may issue additional RFPs with

3-28

respect to subsequent implementation years.

3-29

     (3) The state shall select contractors to carry out this chapter using competitive

3-30

procedures as provided for in the state procurement laws.

3-31

     (4) The state shall enter into a contract under this chapter with an entity only if the entity:

3-32

     (i) Can demonstrate appropriate technical, analytical and clinical knowledge and

3-33

experience to carry out the functions included in this chapter; or

4-34

     (ii) Has a contract, or will enter into a contract, with another entity that meets the above

4-35

criteria.

4-36

     (5) The state shall only enter into a contract under this chapter with an entity to the extent

4-37

the entity complies with conflict of interest standards in the state procurement laws.

4-38

     23-87-12. Access to data. -- The state shall provide entities with a contract under this

4-39

chapter with appropriate access to claims and other data necessary for the entity to carry out the

4-40

functions included in this chapter, including, but not limited to: providing current and historical

4-41

correctional healthcare claims and provider database information; and taking necessary regulatory

4-42

action to facilitate appropriate public-private data sharing, including across multiple correctional

4-43

managed care entities.

4-44

     23-87-13. Reporting. -- The following reports shall be completed by the department of

4-45

health:

4-46

     (1) Not later than three (3) months after the completion of the first implementation year

4-47

under this chapter, the department of health shall submit, on an annual basis, to the house and

4-48

senate finance committees, and make available to the public a report that includes the following:

4-49

     (i) A description of the implementation and use of technologies included in this chapter

4-50

during the year;

4-51

     (ii) A certification by the department of health that specifies the actual and projected

4-52

savings to state correctional healthcare programs as a result of the use of these technologies,

4-53

including estimates of the amounts of such savings with respect to both improper payments

4-54

recovered and improper payments avoided;

4-55

     (iii) The actual and projected savings in correctional healthcare services as a result of

4-56

such use of technologies relative to the return on investment for the use of such technologies and

4-57

in comparison to other strategies or technologies used to prevent and detect inappropriate,

4-58

inaccurate or erroneous activity;

4-59

     (iv) Any modifications or refinements that should be made to increase the amount of

4-60

actual or projected savings or mitigate any adverse impact on correctional healthcare beneficiaries

4-61

or providers;

4-62

     (v) An analysis of the extent to which the use of these technologies successfully

4-63

prevented and detected inappropriate, inaccurate or erroneous activity in correctional healthcare

4-64

programs;

4-65

     (vi) A review of whether the technologies affected access to, or the quality of, items and

4-66

services furnished to correctional healthcare beneficiaries; and

4-67

     (vii) A review of what effect, if any, the use of these technologies had on correctional

4-68

healthcare providers, including assessment of provider education efforts and documentation of

5-1

processes for providers to review and correct problems that are identified.

5-2

     (2) Not later than three (3) months after the completion of the second (2nd)

5-3

implementation year under this chapter, the department of health shall submit, on an annual basis,

5-4

to the house and senate finance committees, and make available to the public a report that

5-5

includes, with respect to such year, the items required under subdivision (1) as well as any other

5-6

additional items deemed appropriate with respect to the report for such year.

5-7

     (3) Not later than three (3) months after the completion of the third (3rd) implementation

5-8

year under this chapter, the department of health shall submit, on an annual basis, to the house

5-9

and senate finance committees, and make available to the public a report that includes with

5-10

respect to such year, the items required under subdivision (1), as well as any other additional

5-11

items deemed appropriate with respect to the report for such year.

5-12

     23-87-14. Shared savings. -- It is the intent of the general assembly that the savings

5-13

achieved through this chapter shall more than cover the costs of implementation. Therefore, to the

5-14

extent possible, technology services used in carrying out this chapter shall be secured using a

5-15

shared savings model, whereby the state’s only direct cost will be a percentage of actual savings

5-16

achieved. Further, to enable this model, a percentage of achieved savings may be used to fund

5-17

expenditures under this chapter.

5-18

     23-87-15. Severability. -- If any section, paragraph, sentence, clause, phrase, or any part

5-19

of the chapter passed is declared invalid, the remaining sections, paragraphs, sentences, clauses,

5-20

phrases, or parts thereof shall be in no manner affected and shall remain in full force and effect.

5-21

     SECTION 2. This act shall take effect upon passage.

     

=======

LC00558

=======

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO HEATH AND SAFETY -- CORRECTIONAL HEALTHCARE ACT

***

6-1

     This act would establish the correctional healthcare act in order to reduce the costs of

6-2

correctional healthcare.

6-3

     This act would take effect upon passage.

     

=======

LC00558

=======

S2090