26-18-2.3 - Division responsibilities -- Emphasis -- Periodic assessment.
26-18-2.3. Division responsibilities -- Emphasis -- Periodic assessment.
(1) In accordance with the requirements of Title XIX of the Social Security Act andapplicable federal regulations, the division is responsible for the effective and impartialadministration of this chapter in an efficient, economical manner. The division shall:
(a) establish, on a statewide basis, a program to safeguard against unnecessary orinappropriate use of Medicaid services, excessive payments, and unnecessary or inappropriatehospital admissions or lengths of stay;
(b) deny any provider claim for services that fail to meet criteria established by thedivision concerning medical necessity or appropriateness; and
(c) place its emphasis on high quality care to recipients in the most economical andcost-effective manner possible, with regard to both publicly and privately provided services.
(2) The division shall implement and utilize cost-containment methods, where possible,which may include:
(a) prepayment and postpayment review systems to determine if utilization is reasonableand necessary;
(b) preadmission certification of nonemergency admissions;
(c) mandatory outpatient, rather than inpatient, surgery in appropriate cases;
(d) second surgical opinions;
(e) procedures for encouraging the use of outpatient services;
(f) consistent with Sections 26-18-2.4 and 58-17b-606, a Medicaid drug program;
(g) coordination of benefits; and
(h) review and exclusion of providers who are not cost effective or who have abused theMedicaid program, in accordance with the procedures and provisions of federal law andregulation.
(3) The director of the division shall periodically assess the cost effectiveness and healthimplications of the existing Medicaid program, and consider alternative approaches to theprovision of covered health and medical services through the Medicaid program, in order toreduce unnecessary or unreasonable utilization.
(4) The department shall ensure Medicaid program integrity by conducting internalaudits of the Medicaid program for efficiencies, best practices, fraud, waste, abuse, and costrecovery, at least in proportion to the percent of funding for the program that comes from statefunds.
(5) The department shall, by December 31 of each year, report to the Health and HumanServices Appropriations Subcommittee regarding:
(a) measures taken under this section to increase:
(i) efficiencies within the program; and
(ii) cost avoidance and cost recovery efforts in the program; and
(b) results of program integrity efforts under Subsection (4).
Amended by Chapter 149, 2010 General Session