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Utah Medicaid cop survives to fight another day

Published March 11, 2013 3:29 pm

Health reform • Compromise bill urges discretion in pursuing honest mistakes, but extends new fraud-fighting tools.
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Utah's Medicaid Inspector General survived legislative attempts to weaken his policing powers with passage of a bill to extend his appointment by two years.

Two opposing bills — one to insulate Medicaid's top cop from politics, and another that some say limits his powers — are now rolled into one. The substituted version of HB106 passed the Senate on Monday and needs only the governor's signature to become law.

The bill would move Inspector General Lee Wyckoff an arm's length from the governor to the Department of Administrative Services. The position would not report to the agency's director, but would be independent — appointed by the governor with consent from the Senate to a four-year term.

It adds elements of HB315, clarifying the Legislature's intent in creating the inspector to crack down on the waste and abuse of Medicaid funds, after a string of legislative probes that found widespread "upcoding," or overcharging, by doctors and hospitals.

The bill directs the inspector general's office to pursue its watchdog role without alienating the declining number of doctors willing to treat Medicaid patients and to differentiate "between honest mistakes and intentional errors, or fraud" if negotiating a settlement.

A prior version of HB315 would have required whistle-blowing health care workers to first report billing errors to their employer. Now the bill would give employees the option of alerting the inspector.

It would also give Wyckoff's team of auditors access to Utah's Controlled Substance Database, empowering them to pursue patient fraud, or doctor-shopping.

Doing so would set Utah apart from most other states which, according to a report by the Pew Charitable Trusts, focus primarily on "pay and chase" efforts to remedy billing errors.

Fraud and abuse in Medicaid waste money and can subject patients to unnecessary or ineffective tests and treatments, the report says. In 2012, an estimated $19 billion — or 7 percent — of federal Medicaid funds was absorbed by improper payments, which include fraud and abuse as well as unintentional mistakes such as paperwork errors.





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