SB13-137 Summary

• State Department must issue a request for information by September 30, 2013 to evaluate advanced predictive analytics and fraud detection technologies for the Medicaid program.

• Technologies must identify high-risk billing and utilization patterns, integrate into existing claims operations, and prevent payment of potentially fraudulent claims before reimbursement occurs.

• State Department should use request results to create formal contractor proposals if expected state savings are generated, work integrates without additional costs, and legitimate claims payments are not delayed or improperly denied.

• Prior to awarding any contract, State Department must establish an appeal process for providers that minimizes administrative burden, limits medical records requests, and allows adequate response time.

• Program implementation costs must be funded through actual savings achieved by the fraud prevention system, with savings exceeding the cost of implementation and administration.