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205.6318 Cabinet to establish integrated system to enhance program integrity of Medical Assistance Program.

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Page 1 of 1 205.6318 Cabinet to establish integrated system to enhance program integrity of Medical Assistance Program. The Cabinet for Health and Family Services shall review the available technology <br>associated with the medical assistance system to determine which technology is best <br>suited to enhance program service operation, monitoring ability, and fraud and abuse <br>detection. This shall include the ability to provide on-line access to data files to allow <br>cross-analysis of provider and recipient utilization patterns. The cabinet shall by <br>promulgation of administrative regulations, pursuant to KRS Chapter 13A, establish an <br>integrated system to enhance program integrity, using a combination of staff, computer <br>technology, and contractual services to identify potential fraud, abuse, and misutilization <br>of services. This system shall: <br>(1) Utilize statisticians, program specialists, accountants, nurses, and other medical specialists to review the Medical Assistance Program to identify patterns of <br>provider and recipient behavior that contributes to unnecessary or abusive use of <br>program services; (2) Utilize computer capability through contractual services or the purchase of computer software to detect the unbundling of claims and other techniques used by <br>providers to enhance reimbursement; (3) Impose utilization controls on the expenditures in respiratory, physical, speech, and occupational therapy and durable medical equipment provided to nursing-home <br>residents, through the use of established medical criteria or preauthorization of <br>ancillary therapies; (4) Establish state audit and edit requirements that exceed the federal audit and edit requirements; (5) Obtain access to necessary data from the fiscal agent of each medical provider; <br>(6) Review the efficiency and effectiveness of the fraud and abuse detection and investigation process to determine whether changes shall be made; (7) Direct that fraud and abuse detection and investigation components shall be active in initiating investigations. The fraud and abuse detection, investigation, and <br>prosecution functions shall be integrated, with access to information in files <br>maintained by the Department for Community Based Services and the Department <br>for Medicaid Services; (8) Review penalties for deterrent value for medical providers that are found to have abused Medicaid regulations and statutes; and (9) Provide for a proactive effort to reduce costs for institutionalized program participants. Program officials shall seek to implement innovative or experimental <br>demonstration programs that aim to control costs. Effective: June 20, 2005 <br>History: Amended 2005 Ky. Acts ch. 99, sec. 251, effective June 20, 2005. -- Amended 2000 Ky. Acts ch. 14, sec. 33, effective July 14, 2000. -- Amended 1998 Ky. Acts <br>ch. 426, sec. 209, effective July 15, 1998. -- Created 1994 Ky. Acts ch. 512, sec. 76, <br>effective July 15, 1994.