Title 42
State Affairs and Government

Chapter 7.2
Office of Health and Human Services

§ 42-7.2-18. Program integrity division.

(a) There is hereby established a program integrity division within the office of health and human services to effectuate the transfer of functions pursuant to § 42-7.2-6.1(a)(7). The purposes of this division are:

(1) To develop and implement a statewide strategy to coordinate state and local agencies, law enforcement entities, and investigative units in order to increase the effectiveness of programs and initiatives dealing with the prevention, detection, and prosecution of Medicaid and public assistance fraud;

(2) To oversee and coordinate state and local efforts to investigate and eliminate Medicaid and public assistance fraud and to recover state and federal funds; and

(3) To pursue any opportunities to enhance health and human services program integrity efforts available under the federal Affordable Care Act of 2010, or any such federal or state laws or regulations pertaining to publicly-funded health and human services administered by the departments assigned to the executive office.

(b) The program integrity division shall provide advice and make recommendations, as necessary, to the secretary of health and human services and all departments assigned to the office to effectuate the purposes of the division. The division shall also propose and execute, with the secretary’s approval, recommendations that assure the office and the departments implement in a timely and effective manner corrective actions to remediate any federal and/or state audit findings when warranted.

(c) The division shall have the following powers and duties:

(1) To conduct a census of local, state, and federal efforts to address Medicaid and public assistance fraud in this state, including fraud detection, prevention, and prosecution, in order to discern overlapping missions, maximize existing resources, and strengthen current programs;

(2) To develop a strategic plan for coordinating and targeting state and local resources for preventing and prosecuting Medicaid and public assistance fraud. The plan must identify methods to enhance multi-agency efforts that contribute to achieving the state’s goal of eliminating Medicaid and public assistance fraud;

(3) To identify methods to implement innovative technology and data sharing in consultation with the office of digital excellence in order to detect and analyze Medicaid and public assistance fraud with speed and efficiency. Such methods as may be effective as a means of detecting incidences of fraud, assisting in directing the focus of an investigation or audit, and determining the amounts a provider owes as the result of such an investigation or audit conducted by the division, a department assigned to the office, Rhode Island Department of Attorney General Medicaid Fraud Control Unit, the U.S. Department of Health and Human Services’ Office of Inspector General, the U.S. Department of Justice’s Federal Bureau of Investigation, or an authorized agent thereof.

(4) To develop and promote, in consultation with federal, state and local law enforcement agencies, crime prevention services and educational programs that serve the public; and

(5) To develop and implement electronic fraud monitoring systems and provide training for all Medicaid provider and managed care organizations on the use of such systems and other fraud detection and prevention mechanisms, concerning, but not limited to the following:

(i) Coverage and billing policies;

(ii) Participant-centered planning and options available;

(iii) Covered and non-covered services;

(iv) Provider accountability and responsibilities;

(v) Claim submission policies and procedures; and

(vi) Reconciling claim activity.

(d) The division shall annually prepare and submit a report on its activities and recommendations, by January 1, to the president of the senate, the speaker of the house of representatives, the governor, and the chairs of the house of representatives and senate finance committees.