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H.B. 84 Enrolled

             1     

OFFICE OF INSPECTOR GENERAL OF MEDICAID

             2     
SERVICES

             3     
2011 GENERAL SESSION

             4     
STATE OF UTAH

             5     
Chief Sponsor: David Clark

             6     
Senate Sponsor: Wayne L. Niederhauser

             7     
             8      LONG TITLE
             9      General Description:
             10          This bill creates, within the Governor's Office of Planning and Budget, the Office of
             11      Inspector General of Medicaid Services.
             12      Highlighted Provisions:
             13          This bill:
             14          .    defines terms;
             15          .    creates, within the Governor's Office of Planning and Budget, the Office of
             16      Inspector General of Medicaid Services (office);
             17          .    describes and provides for the qualifications, appointment, term of office, and
             18      removal of the Inspector General of Medicaid Services (inspector general);
             19          .    describes the duties and powers of the inspector general and the office;
             20          .    requires the inspector general to enter into a memorandum of understanding with
             21      the Medicaid Fraud Control Unit of the attorney general's office (fraud unit);
             22          .    requires the office to annually select and review a representative sample of claims
             23      submitted for reimbursement under the state Medicaid program to determine
             24      whether fraud, waste, or abuse occurred;
             25          .    provides for the transfer of full-time equivalents from the Department of Health to
             26      the Governor's Office of Planning and Budget to staff the office;
             27          .    establishes a process where the inspector general can order a hold on the payment of
             28      a claim for reimbursement submitted by a claimant if there is reasonable cause to
             29      believe that the claim, or payment of the claim, constitutes fraud, waste, or abuse, or


             30      is otherwise inaccurate;
             31          .    grants the office full access to records and employees when investigating or auditing
             32      the use or expenditure of Medicaid funds or the provision of services;
             33          .    grants the office access to the Controlled Substance Database and to all records,
             34      information, and databases that the Department of Health and the Division of Health
             35      Care Financing have access to;
             36          .    requires the Department of Health, the Division of Health Care Financing, and
             37      others to fully cooperate with and support the inspector general and the office in
             38      fulfilling the duties of the inspector general and the office;
             39          .    prohibits a person from interfering with or impeding an investigation or audit of the
             40      office or fraud unit and from interfering with the content or conclusion of a report;
             41          .    grants subpoena power to the inspector general;
             42          .    requires a health care professional, a Medicaid provider, and a state or local
             43      government official or employee to report any Medicaid fraud, waste, or abuse of
             44      which they become aware;
             45          .    requires the inspector general to, on an annual basis, prepare a written report on the
             46      activities of the office for the preceding fiscal year, to provide the report to the
             47      governor, and to provide and present the report to the Executive Appropriations
             48      Committee of the Legislature;
             49          .    requires the provision of contract services to the office by the attorney general's
             50      office and the Division of Health Care Financing;
             51          .    classifies certain records relating to an investigation or audit by the office as
             52      protected;
             53          .    grants rulemaking authority to the office; and
             54          .    makes technical changes.
             55      Money Appropriated in this Bill:
             56          This bill appropriates, as ongoing appropriations:
             57          .    to Department of Health - Executive Director's Operations:


             58              .    from the General Fund, $(694,900);
             59              .    from the Federal Fund, $(1,037,000); and
             60              .    from Revenue Transfers - Within Agency, $(81,500);
             61          .    to Medicaid Mandatory Services:
             62              .    from the General Fund, $(300,000); and
             63              .    from the Federal Fund, $(519,100); and
             64          .    to Office of Inspector General of Medicaid Services:
             65              .    from the General Fund, $994,900;
             66              .    from the Federal Fund, $1,556,100; and
             67              .    from Revenue Transfers - Health, $81,500.
             68      Other Special Clauses:
             69          This bill takes effect on July 1, 2011.
             70      Utah Code Sections Affected:
             71      AMENDS:
             72          26-18-2.3, as last amended by Laws of Utah 2010, Chapter 149
             73          26-18-3, as last amended by Laws of Utah 2010, Chapters 149, 323, 340, and 391
             74          58-37f-301, as enacted by Laws of Utah 2010, Chapter 287 and last amended by
             75      Coordination Clause, Laws of Utah 2010, Chapter 312
             76          63G-2-305, as last amended by Laws of Utah 2010, Chapters 6, 113, and 247
             77          63I-2-263, as last amended by Laws of Utah 2010, Chapter 224
             78          63J-4-202, as renumbered and amended by Laws of Utah 2008, Chapter 382
             79      ENACTS:
             80          63J-4a-101, Utah Code Annotated 1953
             81          63J-4a-102, Utah Code Annotated 1953
             82          63J-4a-201, Utah Code Annotated 1953
             83          63J-4a-202, Utah Code Annotated 1953
             84          63J-4a-203, Utah Code Annotated 1953
             85          63J-4a-204, Utah Code Annotated 1953


             86          63J-4a-205, Utah Code Annotated 1953
             87          63J-4a-206, Utah Code Annotated 1953
             88          63J-4a-207, Utah Code Annotated 1953
             89          63J-4a-301, Utah Code Annotated 1953
             90          63J-4a-302, Utah Code Annotated 1953
             91          63J-4a-303, Utah Code Annotated 1953
             92          63J-4a-304, Utah Code Annotated 1953
             93          63J-4a-401, Utah Code Annotated 1953
             94          63J-4a-501, Utah Code Annotated 1953
             95          63J-4a-502, Utah Code Annotated 1953
             96          63J-4a-601, Utah Code Annotated 1953
             97          63J-4a-602, Utah Code Annotated 1953
             98     
             99      Be it enacted by the Legislature of the state of Utah:
             100          Section 1. Section 26-18-2.3 is amended to read:
             101           26-18-2.3. Division responsibilities -- Emphasis -- Periodic assessment.
             102          (1) In accordance with the requirements of Title XIX of the Social Security Act and
             103      applicable federal regulations, the division is responsible for the effective and impartial
             104      administration of this chapter in an efficient, economical manner. The division shall:
             105          (a) establish, on a statewide basis, a program to safeguard against unnecessary or
             106      inappropriate use of Medicaid services, excessive payments, and unnecessary or inappropriate
             107      hospital admissions or lengths of stay;
             108          (b) deny any provider claim for services that fail to meet criteria established by the
             109      division concerning medical necessity or appropriateness; and
             110          (c) place its emphasis on high quality care to recipients in the most economical and
             111      cost-effective manner possible, with regard to both publicly and privately provided services.
             112          (2) The division shall implement and utilize cost-containment methods, where
             113      possible, which may include:


             114          (a) prepayment and postpayment review systems to determine if utilization is
             115      reasonable and necessary;
             116          (b) preadmission certification of nonemergency admissions;
             117          (c) mandatory outpatient, rather than inpatient, surgery in appropriate cases;
             118          (d) second surgical opinions;
             119          (e) procedures for encouraging the use of outpatient services;
             120          (f) consistent with Sections 26-18-2.4 and 58-17b-606 , a Medicaid drug program;
             121          (g) coordination of benefits; and
             122          (h) review and exclusion of providers who are not cost effective or who have abused
             123      the Medicaid program, in accordance with the procedures and provisions of federal law and
             124      regulation.
             125          (3) The director of the division shall periodically assess the cost effectiveness and
             126      health implications of the existing Medicaid program, and consider alternative approaches to
             127      the provision of covered health and medical services through the Medicaid program, in order to
             128      reduce unnecessary or unreasonable utilization.
             129          (4) The department shall ensure Medicaid program integrity by conducting internal
             130      audits of the Medicaid program for efficiencies, best practices, fraud, waste, abuse, and cost
             131      recovery[, at least in proportion to the percent of funding for the program that comes from state
             132      funds].
             133          (5) The department shall, by December 31 of each year, report to the Health and
             134      Human Services Appropriations Subcommittee regarding:
             135          (a) measures taken under this section to increase:
             136          (i) efficiencies within the program; and
             137          (ii) cost avoidance and cost recovery efforts in the program; and
             138          (b) results of program integrity efforts under Subsection (4).
             139          Section 2. Section 26-18-3 is amended to read:
             140           26-18-3. Administration of Medicaid program by department -- Reporting to the
             141      Legislature -- Disciplinary measures and sanctions -- Funds collected -- Eligibility


             142      standards -- Internal audits -- Studies -- Health opportunity accounts.
             143          (1) The department shall be the single state agency responsible for the administration
             144      of the Medicaid program in connection with the United States Department of Health and
             145      Human Services pursuant to Title XIX of the Social Security Act.
             146          (2) (a) The department shall implement the Medicaid program through administrative
             147      rules in conformity with this chapter, Title 63G, Chapter 3, Utah Administrative Rulemaking
             148      Act, the requirements of Title XIX, and applicable federal regulations.
             149          (b) The rules adopted under Subsection (2)(a) shall include, in addition to other rules
             150      necessary to implement the program:
             151          (i) the standards used by the department for determining eligibility for Medicaid
             152      services;
             153          (ii) the services and benefits to be covered by the Medicaid program; and
             154          (iii) reimbursement methodologies for providers under the Medicaid program.
             155          (3) (a) The department shall, in accordance with Subsection (3)(b), report to the Health
             156      and Human Services Appropriations Subcommittee when the department:
             157          (i) implements a change in the Medicaid State Plan;
             158          (ii) initiates a new Medicaid waiver;
             159          (iii) initiates an amendment to an existing Medicaid waiver;
             160          (iv) applies for an extension of an application for a waiver or an existing Medicaid
             161      waiver; or
             162          (v) initiates a rate change that requires public notice under state or federal law.
             163          (b) The report required by Subsection (3)(a) shall:
             164          (i) be submitted to the Health and Human Services Appropriations Subcommittee prior
             165      to the department implementing the proposed change; and
             166          (ii) include:
             167          (A) a description of the department's current practice or policy that the department is
             168      proposing to change;
             169          (B) an explanation of why the department is proposing the change;


             170          (C) the proposed change in services or reimbursement, including a description of the
             171      effect of the change;
             172          (D) the effect of an increase or decrease in services or benefits on individuals and
             173      families;
             174          (E) the degree to which any proposed cut may result in cost-shifting to more expensive
             175      services in health or human service programs; and
             176          (F) the fiscal impact of the proposed change, including:
             177          (I) the effect of the proposed change on current or future appropriations from the
             178      Legislature to the department;
             179          (II) the effect the proposed change may have on federal matching dollars received by
             180      the state Medicaid program;
             181          (III) any cost shifting or cost savings within the department's budget that may result
             182      from the proposed change; and
             183          (IV) identification of the funds that will be used for the proposed change, including any
             184      transfer of funds within the department's budget.
             185          (4) (a) The Department of Human Services shall report to the Legislative Health and
             186      Human Services Appropriations Subcommittee no later than December 31, 2010 in accordance
             187      with Subsection (4)(b).
             188          (b) The report required by Subsection (4)(a) shall include:
             189          (i) changes made by the division or the department beginning July 1, 2010 that effect
             190      the Medicaid program, a waiver under the Medicaid program, or an interpretation of Medicaid
             191      services or funding, that relate to care for children and youth in the custody of the Division of
             192      Child and Family Services or the Division of Juvenile Justice Services;
             193          (ii) the history and impact of the changes under Subsection (4)(b)(i);
             194          (iii) the Department of Human Service's plans for addressing the impact of the changes
             195      under Subsection (4)(b)(i); and
             196          (iv) ways to consolidate administrative functions within the Department of Human
             197      Services, the Department of Health, the Division of Child and Family Services, and the


             198      Division of Juvenile Justice Services to more efficiently meet the needs of children and youth
             199      with mental health and substance disorder treatment needs.
             200          (5) Any rules adopted by the department under Subsection (2) are subject to review and
             201      reauthorization by the Legislature in accordance with Section 63G-3-502 .
             202          (6) The department may, in its discretion, contract with the Department of Human
             203      Services or other qualified agencies for services in connection with the administration of the
             204      Medicaid program, including:
             205          (a) the determination of the eligibility of individuals for the program;
             206          (b) recovery of overpayments; and
             207          (c) consistent with Section 26-20-13 , and to the extent permitted by law and quality
             208      control services, enforcement of fraud and abuse laws.
             209          (7) The department shall provide, by rule, disciplinary measures and sanctions for
             210      Medicaid providers who fail to comply with the rules and procedures of the program, provided
             211      that sanctions imposed administratively may not extend beyond:
             212          (a) termination from the program;
             213          (b) recovery of claim reimbursements incorrectly paid; and
             214          (c) those specified in Section 1919 of Title XIX of the federal Social Security Act.
             215          (8) Funds collected as a result of a sanction imposed under Section 1919 of Title XIX
             216      of the federal Social Security Act shall be deposited in the General Fund as dedicated credits to
             217      be used by the division in accordance with the requirements of Section 1919 of Title XIX of
             218      the federal Social Security Act.
             219          (9) (a) In determining whether an applicant or recipient is eligible for a service or
             220      benefit under this part or Chapter 40, Utah Children's Health Insurance Act, the department
             221      shall, if Subsection (9)(b) is satisfied, exclude from consideration one passenger vehicle
             222      designated by the applicant or recipient.
             223          (b) Before Subsection (9)(a) may be applied:
             224          (i) the federal government must:
             225          (A) determine that Subsection (9)(a) may be implemented within the state's existing


             226      public assistance-related waivers as of January 1, 1999;
             227          (B) extend a waiver to the state permitting the implementation of Subsection (9)(a); or
             228          (C) determine that the state's waivers that permit dual eligibility determinations for
             229      cash assistance and Medicaid are no longer valid; and
             230          (ii) the department must determine that Subsection (9)(a) can be implemented within
             231      existing funding.
             232          (10) (a) For purposes of this Subsection (10):
             233          (i) "aged, blind, or disabled" shall be defined by administrative rule; and
             234          (ii) "spend down" means an amount of income in excess of the allowable income
             235      standard that must be paid in cash to the department or incurred through the medical services
             236      not paid by Medicaid.
             237          (b) In determining whether an applicant or recipient who is aged, blind, or disabled is
             238      eligible for a service or benefit under this chapter, the department shall use 100% of the federal
             239      poverty level as:
             240          (i) the allowable income standard for eligibility for services or benefits; and
             241          (ii) the allowable income standard for eligibility as a result of spend down.
             242          (11) The department shall conduct internal audits of the Medicaid program[, in
             243      proportion to at least the level of funding it receives from Medicaid to conduct internal audits].
             244          (12) In order to determine the feasibility of contracting for direct Medicaid providers
             245      for primary care services, the department shall:
             246          (a) issue a request for information for direct contracting for primary services that shall
             247      provide that a provider shall exclusively serve all Medicaid clients:
             248          (i) in a geographic area;
             249          (ii) for a defined range of primary care services; and
             250          (iii) for a predetermined total contracted amount; and
             251          (b) by February 1, 2011, report to the Health and Human Services Appropriations
             252      Subcommittee on the response to the request for information under Subsection (12)(a).
             253          (13) (a) By December 31, 2010, the department shall:


             254          (i) determine the feasibility of implementing a three year patient-centered medical
             255      home demonstration project in an area of the state using existing budget funds; and
             256          (ii) report the department's findings and recommendations under Subsection (13)(a)(i)
             257      to the Health and Human Services Appropriations Subcommittee.
             258          (b) If the department determines that the medical home demonstration project
             259      described in Subsection (13)(a) is feasible, and the Health and Human Services Appropriations
             260      Subcommittee recommends that the demonstration project be implemented, the department
             261      shall:
             262          (i) implement the demonstration project; and
             263          (ii) by December 1, 2012, make recommendations to the Health and Human Services
             264      Appropriations Subcommittee regarding the:
             265          (A) continuation of the demonstration project;
             266          (B) expansion of the demonstration project to other areas of the state; and
             267          (C) cost savings incurred by the implementation of the demonstration project.
             268          (14) (a) The department may apply for and, if approved, implement a demonstration
             269      program for health opportunity accounts, as provided for in 42 U.S.C. Sec. 1396u-8.
             270          (b) A health opportunity account established under Subsection (14)(a) shall be an
             271      alternative to the existing benefits received by an individual eligible to receive Medicaid under
             272      this chapter.
             273          (c) Subsection (14)(a) is not intended to expand the coverage of the Medicaid program.
             274          Section 3. Section 58-37f-301 is amended to read:
             275           58-37f-301. Access to database.
             276          (1) The division shall make rules, in accordance with Title 63G, Chapter 3, Utah
             277      Administrative Rulemaking Act, to:
             278          (a) effectively enforce the limitations on access to the database as described in this
             279      part; and
             280          (b) establish standards and procedures to ensure accurate identification of individuals
             281      requesting information or receiving information without request from the database.


             282          (2) The division shall make information in the database available only to the following
             283      individuals, in accordance with the requirements of this chapter and division rules:
             284          (a) personnel of the division specifically assigned to conduct investigations related to
             285      controlled substance laws under the jurisdiction of the division;
             286          (b) authorized division personnel engaged in analysis of controlled substance
             287      prescription information as a part of the assigned duties and responsibilities of their
             288      employment;
             289          (c) in accordance with a written agreement entered into with the department,
             290      employees of the Department of Health:
             291          (i) whom the director of the Department of Health assigns to conduct scientific studies
             292      regarding the use or abuse of controlled substances, provided that the identity of the individuals
             293      and pharmacies in the database are confidential and are not disclosed in any manner to any
             294      individual who is not directly involved in the scientific studies; or
             295          (ii) when the information is requested by the Department of Health in relation to a
             296      person whom the Department of Health suspects may be improperly obtaining or providing a
             297      controlled substance;
             298          (d) a licensed practitioner having authority to prescribe controlled substances, to the
             299      extent the information:
             300          (i) (A) relates specifically to a current or prospective patient of the practitioner; and
             301          (B) is sought by the practitioner for the purpose of:
             302          (I) prescribing or considering prescribing any controlled substance to the current or
             303      prospective patient;
             304          (II) diagnosing the current or prospective patient;
             305          (III) providing medical treatment or medical advice to the current or prospective
             306      patient; or
             307          (IV) determining whether the current or prospective patient:
             308          (Aa) is attempting to fraudulently obtain a controlled substance from the practitioner;
             309      or


             310          (Bb) has fraudulently obtained, or attempted to fraudulently obtain, a controlled
             311      substance from the practitioner;
             312          (ii) (A) relates specifically to a former patient of the practitioner; and
             313          (B) is sought by the practitioner for the purpose of determining whether the former
             314      patient has fraudulently obtained, or has attempted to fraudulently obtain, a controlled
             315      substance from the practitioner;
             316          (iii) relates specifically to an individual who has access to the practitioner's Drug
             317      Enforcement Administration identification number, and the practitioner suspects that the
             318      individual may have used the practitioner's Drug Enforcement Administration identification
             319      number to fraudulently acquire or prescribe a controlled substance;
             320          (iv) relates to the practitioner's own prescribing practices, except when specifically
             321      prohibited by the division by administrative rule;
             322          (v) relates to the use of the controlled substance database by an employee of the
             323      practitioner, described in Subsection (2)(e); or
             324          (vi) relates to any use of the practitioner's Drug Enforcement Administration
             325      identification number to obtain, attempt to obtain, prescribe, or attempt to prescribe, a
             326      controlled substance;
             327          (e) in accordance with Subsection (3)(a), an employee of a practitioner described in
             328      Subsection (2)(d), for a purpose described in Subsection (2)(d)(i) or (ii), if:
             329          (i) the employee is designated by the practitioner as an individual authorized to access
             330      the information on behalf of the practitioner;
             331          (ii) the practitioner provides written notice to the division of the identity of the
             332      employee; and
             333          (iii) the division:
             334          (A) grants the employee access to the database; and
             335          (B) provides the employee with a password that is unique to that employee to access
             336      the database in order to permit the division to comply with the requirements of Subsection
             337      58-37f-203 (3)(b) with respect to the employee;


             338          (f) a licensed pharmacist having authority to dispense a controlled substance to the
             339      extent the information is sought for the purpose of:
             340          (i) dispensing or considering dispensing any controlled substance; or
             341          (ii) determining whether a person:
             342          (A) is attempting to fraudulently obtain a controlled substance from the pharmacist; or
             343          (B) has fraudulently obtained, or attempted to fraudulently obtain, a controlled
             344      substance from the pharmacist;
             345          (g) federal, state, and local law enforcement authorities, and state and local
             346      prosecutors, engaged as a specified duty of their employment in enforcing laws:
             347          (i) regulating controlled substances; or
             348          (ii) investigating insurance fraud, Medicaid fraud, or Medicare fraud;
             349          (h) a mental health therapist, if:
             350          (i) the information relates to a patient who is:
             351          (A) enrolled in a licensed substance abuse treatment program; and
             352          (B) receiving treatment from, or under the direction of, the mental health therapist as
             353      part of the patient's participation in the licensed substance abuse treatment program described
             354      in Subsection (2)(h)(i)(A);
             355          (ii) the information is sought for the purpose of determining whether the patient is
             356      using a controlled substance while the patient is enrolled in the licensed substance abuse
             357      treatment program described in Subsection (2)(h)(i)(A); and
             358          (iii) the licensed substance abuse treatment program described in Subsection
             359      (2)(h)(i)(A) is associated with a practitioner who:
             360          (A) is a physician, a physician assistant, an advance practice registered nurse, or a
             361      pharmacist; and
             362          (B) is available to consult with the mental health therapist regarding the information
             363      obtained by the mental health therapist, under this Subsection (2)(h), from the database; [and]
             364          (i) an individual who is the recipient of a controlled substance prescription entered into
             365      the database, upon providing evidence satisfactory to the division that the individual requesting


             366      the information is in fact the individual about whom the data entry was made[.]; and
             367          (j) the inspector general, or a designee of the inspector general, of the Office of
             368      Inspector General of Medicaid Services, for the purpose of fulfilling the duties described in
             369      Title 63J, Chapter 4a, Part 2, Office Duties and Powers.
             370          (3) (a) A practitioner described in Subsection (2)(d) may designate up to three
             371      employees to access information from the database under Subsection (2)(e).
             372          (b) The division shall make rules, in accordance with Title 63G, Chapter 3, Utah
             373      Administrative Rulemaking Act, to establish background check procedures to determine
             374      whether an employee designated under Subsection (2)(e)(i) should be granted access to the
             375      database.
             376          (c) The division shall grant an employee designated under Subsection (2)(e)(i) access
             377      to the database, unless the division determines, based on a background check, that the
             378      employee poses a security risk to the information contained in the database.
             379          (d) The division may impose a fee, in accordance with Section 63J-1-504 , on a
             380      practitioner who designates an employee under Subsection (2)(e)(i), to pay for the costs
             381      incurred by the division to conduct the background check and make the determination
             382      described in Subsection (3)(b).
             383          (4) (a) An individual who is granted access to the database based on the fact that the
             384      individual is a licensed practitioner or a mental health therapist shall be denied access to the
             385      database when the individual is no longer licensed.
             386          (b) An individual who is granted access to the database based on the fact that the
             387      individual is a designated employee of a licensed practitioner shall be denied access to the
             388      database when the practitioner is no longer licensed.
             389          Section 4. Section 63G-2-305 is amended to read:
             390           63G-2-305. Protected records.
             391          The following records are protected if properly classified by a governmental entity:
             392          (1) trade secrets as defined in Section 13-24-2 if the person submitting the trade secret
             393      has provided the governmental entity with the information specified in Section 63G-2-309 ;


             394          (2) commercial information or nonindividual financial information obtained from a
             395      person if:
             396          (a) disclosure of the information could reasonably be expected to result in unfair
             397      competitive injury to the person submitting the information or would impair the ability of the
             398      governmental entity to obtain necessary information in the future;
             399          (b) the person submitting the information has a greater interest in prohibiting access
             400      than the public in obtaining access; and
             401          (c) the person submitting the information has provided the governmental entity with
             402      the information specified in Section 63G-2-309 ;
             403          (3) commercial or financial information acquired or prepared by a governmental entity
             404      to the extent that disclosure would lead to financial speculations in currencies, securities, or
             405      commodities that will interfere with a planned transaction by the governmental entity or cause
             406      substantial financial injury to the governmental entity or state economy;
             407          (4) records the disclosure of which could cause commercial injury to, or confer a
             408      competitive advantage upon a potential or actual competitor of, a commercial project entity as
             409      defined in Subsection 11-13-103 (4);
             410          (5) test questions and answers to be used in future license, certification, registration,
             411      employment, or academic examinations;
             412          (6) records the disclosure of which would impair governmental procurement
             413      proceedings or give an unfair advantage to any person proposing to enter into a contract or
             414      agreement with a governmental entity, except, subject to Subsections (1) and (2), that this
             415      Subsection (6) does not restrict the right of a person to have access to, once the contract or
             416      grant has been awarded, a bid, proposal, or application submitted to or by a governmental
             417      entity in response to:
             418          (a) a request for bids;
             419          (b) a request for proposals;
             420          (c) a grant; or
             421          (d) other similar document;


             422          (7) records that would identify real property or the appraisal or estimated value of real
             423      or personal property, including intellectual property, under consideration for public acquisition
             424      before any rights to the property are acquired unless:
             425          (a) public interest in obtaining access to the information outweighs the governmental
             426      entity's need to acquire the property on the best terms possible;
             427          (b) the information has already been disclosed to persons not employed by or under a
             428      duty of confidentiality to the entity;
             429          (c) in the case of records that would identify property, potential sellers of the described
             430      property have already learned of the governmental entity's plans to acquire the property;
             431          (d) in the case of records that would identify the appraisal or estimated value of
             432      property, the potential sellers have already learned of the governmental entity's estimated value
             433      of the property; or
             434          (e) the property under consideration for public acquisition is a single family residence
             435      and the governmental entity seeking to acquire the property has initiated negotiations to acquire
             436      the property as required under Section 78B-6-505 ;
             437          (8) records prepared in contemplation of sale, exchange, lease, rental, or other
             438      compensated transaction of real or personal property including intellectual property, which, if
             439      disclosed prior to completion of the transaction, would reveal the appraisal or estimated value
             440      of the subject property, unless:
             441          (a) the public interest in access outweighs the interests in restricting access, including
             442      the governmental entity's interest in maximizing the financial benefit of the transaction; or
             443          (b) when prepared by or on behalf of a governmental entity, appraisals or estimates of
             444      the value of the subject property have already been disclosed to persons not employed by or
             445      under a duty of confidentiality to the entity;
             446          (9) records created or maintained for civil, criminal, or administrative enforcement
             447      purposes or audit purposes, or for discipline, licensing, certification, or registration purposes, if
             448      release of the records:
             449          (a) reasonably could be expected to interfere with investigations undertaken for


             450      enforcement, discipline, licensing, certification, or registration purposes;
             451          (b) reasonably could be expected to interfere with audits, disciplinary, or enforcement
             452      proceedings;
             453          (c) would create a danger of depriving a person of a right to a fair trial or impartial
             454      hearing;
             455          (d) reasonably could be expected to disclose the identity of a source who is not
             456      generally known outside of government and, in the case of a record compiled in the course of
             457      an investigation, disclose information furnished by a source not generally known outside of
             458      government if disclosure would compromise the source; or
             459          (e) reasonably could be expected to disclose investigative or audit techniques,
             460      procedures, policies, or orders not generally known outside of government if disclosure would
             461      interfere with enforcement or audit efforts;
             462          (10) records the disclosure of which would jeopardize the life or safety of an
             463      individual;
             464          (11) records the disclosure of which would jeopardize the security of governmental
             465      property, governmental programs, or governmental recordkeeping systems from damage, theft,
             466      or other appropriation or use contrary to law or public policy;
             467          (12) records that, if disclosed, would jeopardize the security or safety of a correctional
             468      facility, or records relating to incarceration, treatment, probation, or parole, that would interfere
             469      with the control and supervision of an offender's incarceration, treatment, probation, or parole;
             470          (13) records that, if disclosed, would reveal recommendations made to the Board of
             471      Pardons and Parole by an employee of or contractor for the Department of Corrections, the
             472      Board of Pardons and Parole, or the Department of Human Services that are based on the
             473      employee's or contractor's supervision, diagnosis, or treatment of any person within the board's
             474      jurisdiction;
             475          (14) records and audit workpapers that identify audit, collection, and operational
             476      procedures and methods used by the State Tax Commission, if disclosure would interfere with
             477      audits or collections;


             478          (15) records of a governmental audit agency relating to an ongoing or planned audit
             479      until the final audit is released;
             480          (16) records prepared by or on behalf of a governmental entity solely in anticipation of
             481      litigation that are not available under the rules of discovery;
             482          (17) records disclosing an attorney's work product, including the mental impressions or
             483      legal theories of an attorney or other representative of a governmental entity concerning
             484      litigation;
             485          (18) records of communications between a governmental entity and an attorney
             486      representing, retained, or employed by the governmental entity if the communications would be
             487      privileged as provided in Section 78B-1-137 ;
             488          (19) (a) (i) personal files of a state legislator, including personal correspondence to or
             489      from a member of the Legislature; and
             490          (ii) notwithstanding Subsection (19)(a)(i), correspondence that gives notice of
             491      legislative action or policy may not be classified as protected under this section; and
             492          (b) (i) an internal communication that is part of the deliberative process in connection
             493      with the preparation of legislation between:
             494          (A) members of a legislative body;
             495          (B) a member of a legislative body and a member of the legislative body's staff; or
             496          (C) members of a legislative body's staff; and
             497          (ii) notwithstanding Subsection (19)(b)(i), a communication that gives notice of
             498      legislative action or policy may not be classified as protected under this section;
             499          (20) (a) records in the custody or control of the Office of Legislative Research and
             500      General Counsel, that, if disclosed, would reveal a particular legislator's contemplated
             501      legislation or contemplated course of action before the legislator has elected to support the
             502      legislation or course of action, or made the legislation or course of action public; and
             503          (b) notwithstanding Subsection (20)(a), the form to request legislation submitted to the
             504      Office of Legislative Research and General Counsel is a public document unless a legislator
             505      asks that the records requesting the legislation be maintained as protected records until such


             506      time as the legislator elects to make the legislation or course of action public;
             507          (21) research requests from legislators to the Office of Legislative Research and
             508      General Counsel or the Office of the Legislative Fiscal Analyst and research findings prepared
             509      in response to these requests;
             510          (22) drafts, unless otherwise classified as public;
             511          (23) records concerning a governmental entity's strategy about collective bargaining or
             512      pending litigation;
             513          (24) records of investigations of loss occurrences and analyses of loss occurrences that
             514      may be covered by the Risk Management Fund, the Employers' Reinsurance Fund, the
             515      Uninsured Employers' Fund, or similar divisions in other governmental entities;
             516          (25) records, other than personnel evaluations, that contain a personal recommendation
             517      concerning an individual if disclosure would constitute a clearly unwarranted invasion of
             518      personal privacy, or disclosure is not in the public interest;
             519          (26) records that reveal the location of historic, prehistoric, paleontological, or
             520      biological resources that if known would jeopardize the security of those resources or of
             521      valuable historic, scientific, educational, or cultural information;
             522          (27) records of independent state agencies if the disclosure of the records would
             523      conflict with the fiduciary obligations of the agency;
             524          (28) records of an institution within the state system of higher education defined in
             525      Section 53B-1-102 regarding tenure evaluations, appointments, applications for admissions,
             526      retention decisions, and promotions, which could be properly discussed in a meeting closed in
             527      accordance with Title 52, Chapter 4, Open and Public Meetings Act, provided that records of
             528      the final decisions about tenure, appointments, retention, promotions, or those students
             529      admitted, may not be classified as protected under this section;
             530          (29) records of the governor's office, including budget recommendations, legislative
             531      proposals, and policy statements, that if disclosed would reveal the governor's contemplated
             532      policies or contemplated courses of action before the governor has implemented or rejected
             533      those policies or courses of action or made them public;


             534          (30) records of the Office of the Legislative Fiscal Analyst relating to budget analysis,
             535      revenue estimates, and fiscal notes of proposed legislation before issuance of the final
             536      recommendations in these areas;
             537          (31) records provided by the United States or by a government entity outside the state
             538      that are given to the governmental entity with a requirement that they be managed as protected
             539      records if the providing entity certifies that the record would not be subject to public disclosure
             540      if retained by it;
             541          (32) transcripts, minutes, or reports of the closed portion of a meeting of a public body
             542      except as provided in Section 52-4-206 ;
             543          (33) records that would reveal the contents of settlement negotiations but not including
             544      final settlements or empirical data to the extent that they are not otherwise exempt from
             545      disclosure;
             546          (34) memoranda prepared by staff and used in the decision-making process by an
             547      administrative law judge, a member of the Board of Pardons and Parole, or a member of any
             548      other body charged by law with performing a quasi-judicial function;
             549          (35) records that would reveal negotiations regarding assistance or incentives offered
             550      by or requested from a governmental entity for the purpose of encouraging a person to expand
             551      or locate a business in Utah, but only if disclosure would result in actual economic harm to the
             552      person or place the governmental entity at a competitive disadvantage, but this section may not
             553      be used to restrict access to a record evidencing a final contract;
             554          (36) materials to which access must be limited for purposes of securing or maintaining
             555      the governmental entity's proprietary protection of intellectual property rights including patents,
             556      copyrights, and trade secrets;
             557          (37) the name of a donor or a prospective donor to a governmental entity, including an
             558      institution within the state system of higher education defined in Section 53B-1-102 , and other
             559      information concerning the donation that could reasonably be expected to reveal the identity of
             560      the donor, provided that:
             561          (a) the donor requests anonymity in writing;


             562          (b) any terms, conditions, restrictions, or privileges relating to the donation may not be
             563      classified protected by the governmental entity under this Subsection (37); and
             564          (c) except for an institution within the state system of higher education defined in
             565      Section 53B-1-102 , the governmental unit to which the donation is made is primarily engaged
             566      in educational, charitable, or artistic endeavors, and has no regulatory or legislative authority
             567      over the donor, a member of the donor's immediate family, or any entity owned or controlled
             568      by the donor or the donor's immediate family;
             569          (38) accident reports, except as provided in Sections 41-6a-404 , 41-12a-202 , and
             570      73-18-13 ;
             571          (39) a notification of workers' compensation insurance coverage described in Section
             572      34A-2-205 ;
             573          (40) (a) the following records of an institution within the state system of higher
             574      education defined in Section 53B-1-102 , which have been developed, discovered, disclosed to,
             575      or received by or on behalf of faculty, staff, employees, or students of the institution:
             576          (i) unpublished lecture notes;
             577          (ii) unpublished notes, data, and information:
             578          (A) relating to research; and
             579          (B) of:
             580          (I) the institution within the state system of higher education defined in Section
             581      53B-1-102 ; or
             582          (II) a sponsor of sponsored research;
             583          (iii) unpublished manuscripts;
             584          (iv) creative works in process;
             585          (v) scholarly correspondence; and
             586          (vi) confidential information contained in research proposals;
             587          (b) Subsection (40)(a) may not be construed to prohibit disclosure of public
             588      information required pursuant to Subsection 53B-16-302 (2)(a) or (b); and
             589          (c) Subsection (40)(a) may not be construed to affect the ownership of a record;


             590          (41) (a) records in the custody or control of the Office of Legislative Auditor General
             591      that would reveal the name of a particular legislator who requests a legislative audit prior to the
             592      date that audit is completed and made public; and
             593          (b) notwithstanding Subsection (41)(a), a request for a legislative audit submitted to the
             594      Office of the Legislative Auditor General is a public document unless the legislator asks that
             595      the records in the custody or control of the Office of Legislative Auditor General that would
             596      reveal the name of a particular legislator who requests a legislative audit be maintained as
             597      protected records until the audit is completed and made public;
             598          (42) records that provide detail as to the location of an explosive, including a map or
             599      other document that indicates the location of:
             600          (a) a production facility; or
             601          (b) a magazine;
             602          (43) information:
             603          (a) contained in the statewide database of the Division of Aging and Adult Services
             604      created by Section 62A-3-311.1 ; or
             605          (b) received or maintained in relation to the Identity Theft Reporting Information
             606      System (IRIS) established under Section 67-5-22 ;
             607          (44) information contained in the Management Information System and Licensing
             608      Information System described in Title 62A, Chapter 4a, Child and Family Services;
             609          (45) information regarding National Guard operations or activities in support of the
             610      National Guard's federal mission;
             611          (46) records provided by any pawn or secondhand business to a law enforcement
             612      agency or to the central database in compliance with Title 13, Chapter 32a, Pawnshop and
             613      Secondhand Merchandise Transaction Information Act;
             614          (47) information regarding food security, risk, and vulnerability assessments performed
             615      by the Department of Agriculture and Food;
             616          (48) except to the extent that the record is exempt from this chapter pursuant to Section
             617      63G-2-106 , records related to an emergency plan or program prepared or maintained by the


             618      Division of Homeland Security the disclosure of which would jeopardize:
             619          (a) the safety of the general public; or
             620          (b) the security of:
             621          (i) governmental property;
             622          (ii) governmental programs; or
             623          (iii) the property of a private person who provides the Division of Homeland Security
             624      information;
             625          (49) records of the Department of Agriculture and Food relating to the National
             626      Animal Identification System or any other program that provides for the identification, tracing,
             627      or control of livestock diseases, including any program established under Title 4, Chapter 24,
             628      Utah Livestock Brand and Anti-theft Act or Title 4, Chapter 31, Livestock Inspection and
             629      Quarantine;
             630          (50) as provided in Section 26-39-501 :
             631          (a) information or records held by the Department of Health related to a complaint
             632      regarding a child care program or residential child care which the department is unable to
             633      substantiate; and
             634          (b) information or records related to a complaint received by the Department of Health
             635      from an anonymous complainant regarding a child care program or residential child care;
             636          (51) unless otherwise classified as public under Section 63G-2-301 and except as
             637      provided under Section 41-1a-116 , an individual's home address, home telephone number, or
             638      personal mobile phone number, if:
             639          (a) the individual is required to provide the information in order to comply with a law,
             640      ordinance, rule, or order of a government entity; and
             641          (b) the subject of the record has a reasonable expectation that this information will be
             642      kept confidential due to:
             643          (i) the nature of the law, ordinance, rule, or order; and
             644          (ii) the individual complying with the law, ordinance, rule, or order;
             645          (52) the name, home address, work addresses, and telephone numbers of an individual


             646      that is engaged in, or that provides goods or services for, medical or scientific research that is:
             647          (a) conducted within the state system of higher education, as defined in Section
             648      53B-1-102 ; and
             649          (b) conducted using animals;
             650          (53) an initial proposal under Title 63M, Chapter 1, Part 26, Government Procurement
             651      Private Proposal Program, to the extent not made public by rules made under that chapter;
             652          (54) information collected and a report prepared by the Judicial Performance
             653      Evaluation Commission concerning a judge, unless Section 20A-7-702 or Title 78A, Chapter
             654      12, Judicial Performance Evaluation Commission Act, requires disclosure of, or makes public,
             655      the information or report;
             656          (55) (a) records of the Utah Educational Savings Plan created under Section
             657      53B-8a-103 if the disclosure of the records would conflict with its fiduciary obligations;
             658          (b) proposals submitted to the Utah Educational Savings Plan; and
             659          (c) contracts entered into by the Utah Educational Savings Plan and the related
             660      payments;
             661          (56) records contained in the Management Information System created in Section
             662      62A-4a-1003 ;
             663          (57) records provided or received by the Public Lands Policy Coordinating Office in
             664      furtherance of any contract or other agreement made in accordance with Section 63J-4-603 ;
             665          (58) information requested by and provided to the Utah State 911 Committee under
             666      Section 53-10-602 ;
             667          (59) recorded Children's Justice Center investigative interviews, both video and audio,
             668      the release of which are governed by Section 77-37-4 ; [and]
             669          (60) in accordance with Section 73-10-33 :
             670          (a) a management plan for a water conveyance facility in the possession of the Division
             671      of Water Resources or the Board of Water Resources; or
             672          (b) an outline of an emergency response plan in possession of the state or a county or
             673      municipality[.];


             674          (61) the following records in the custody or control of the Office of Inspector General
             675      of Medicaid Services, created in Section 63J-4a-201 :
             676          (a) records that would disclose information relating to allegations of personal
             677      misconduct, gross mismanagement, or illegal activity of a person if the information or
             678      allegation cannot be corroborated by the Office of Inspector General of Medicaid Services
             679      through other documents or evidence, and the records relating to the allegation are not relied
             680      upon by the Office of Inspector General of Medicaid Services in preparing a final investigation
             681      report or final audit report;
             682          (b) records and audit workpapers to the extent they would disclose the identity of a
             683      person who, during the course of an investigation or audit, communicated the existence of any
             684      Medicaid fraud, waste, or abuse, or a violation or suspected violation of a law, rule, or
             685      regulation adopted under the laws of this state, a political subdivision of the state, or any
             686      recognized entity of the United States, if the information was disclosed on the condition that
             687      the identity of the person be protected;
             688          (c) before the time that an investigation or audit is completed and the final
             689      investigation or final audit report is released, records or drafts circulated to a person who is not
             690      an employee or head of a governmental entity for the person's response or information;
             691          (d) records that would disclose an outline or part of any investigation, audit survey
             692      plan, or audit program; or
             693          (e) requests for an investigation or audit, if disclosure would risk circumvention of an
             694      investigation or audit; and
             695          (62) records that reveal methods used by the Office of Inspector General of Medicaid
             696      Services, the fraud unit, or the Department of Health, to discover Medicaid fraud, waste, or
             697      abuse.
             698          Section 5. Section 63I-2-263 is amended to read:
             699           63I-2-263. Repeal dates, Title 63A to Title 63M.
             700          (1) Subsection 63G-1-401 (5) is repealed on May 10, 2011.
             701          (2) Sections 63J-4a-206 and 63J-4a-207 are repealed on December 31, 2011.


             702          Section 6. Section 63J-4-202 is amended to read:
             703           63J-4-202. Appointment of director, state planning coordinator, and inspector
             704      general of Medicaid Services.
             705          (1) (a) The governor shall appoint, to serve at the governor's pleasure:
             706          (i) a director of the Governor's Office of Planning and Budget; and
             707          (ii) a state planning coordinator.
             708          (b) The state planning coordinator is considered part of the office for purposes of
             709      administration.
             710          (2) The governor shall establish the director's salary within the salary range fixed by
             711      the Legislature in Title 67, Chapter 22, State Officer Compensation.
             712          (3) (a) In accordance with Section 63J-4a-201 , the governor shall appoint, with the
             713      advice and consent of the Senate, the inspector general of the Office of Inspector General of
             714      Medicaid Services.
             715          (b) The Office of Inspector General of Medicaid Services is considered part of the
             716      office for purposes of administration.
             717          Section 7. Section 63J-4a-101 is enacted to read:
             718     
CHAPTER 4a. OFFICE OF INSPECTOR GENERAL OF MEDICAID SERVICES

             719     
Part 1. General Provisions

             720          63J-4a-101. Title.
             721          This chapter is known as "Office of Inspector General of Medicaid Services."
             722          Section 8. Section 63J-4a-102 is enacted to read:
             723          63J-4a-102. Definitions.
             724          As used in this chapter:
             725          (1) "Abuse" means:
             726          (a) an action or practice that:
             727          (i) is inconsistent with sound fiscal, business, or medical practices; and
             728          (ii) results, or may result, in unnecessary Medicaid related costs; or
             729          (b) reckless or negligent upcoding.


             730          (2) "Claimant" means a person that:
             731          (a) provides a service; and
             732          (b) submits a claim for Medicaid reimbursement for the service.
             733          (3) "Department" means the Department of Health, created in Section 26-1-4 .
             734          (4) "Division" means the Division of Health Care Financing, created in Section
             735      26-18-2.1 .
             736          (5) "Fraud" means intentional or knowing:
             737          (a) deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, a
             738      claim, reimbursement, or services; or
             739          (b) a violation of a provision of Subsections 26-20-3 through 26-20-7 .
             740          (6) "Fraud unit" means the Medicaid Fraud Control Unit of the attorney general's
             741      office.
             742          (7) "Health care professional" means a person licensed under:
             743          (a) Title 58, Chapter 5a, Podiatric Physician Licensing Act;
             744          (b) Title 58, Chapter 16a, Utah Optometry Practice Act;
             745          (c) Title 58, Chapter 17b, Pharmacy Practice Act;
             746          (d) Title 58, Chapter 24b, Physical Therapy Practice Act;
             747          (e) Title 58, Chapter 31b, Nurse Practice Act;
             748          (f) Title 58, Chapter 40, Recreational Therapy Practice Act;
             749          (g) Title 58, Chapter 41, Speech-language Pathology and Audiology Licensing Act;
             750          (h) Title 58, Chapter 42a, Occupational Therapy Practice Act;
             751          (i) Title 58, Chapter 44a, Nurse Midwife Practice Act;
             752          (j) Title 58, Chapter 49, Dietitian Certification Act;
             753          (k) Title 58, Chapter 60, Mental Health Professional Practice Act;
             754          (l) Title 58, Chapter 67, Utah Medical Practice Act;
             755          (m) Title 58, Chapter 68, Utah Osteopathic Medical Practice Act;
             756          (n) Title 58, Chapter 69, Dentist and Dental Hygienist Practice Act;
             757          (o) Title 58, Chapter 70a, Physician Assistant Act; and


             758          (p) Title 58, Chapter 73, Chiropractic Physician Practice Act.
             759          (8) "Inspector general" means the inspector general of the office, appointed under
             760      Section 63J-4a-201 .
             761          (9) "Office" means the Office of Inspector General of Medicaid Services, created in
             762      Section 63J-4a-201 .
             763          (10) "Provider" means a person that provides:
             764          (a) medical assistance, including supplies or services, in exchange, directly or
             765      indirectly, for Medicaid funds; or
             766          (b) billing or recordkeeping services relating to Medicaid funds.
             767          (11) "Upcoding" means assigning an inaccurate billing code for a service that is
             768      payable or reimbursable by Medicaid funds, if the correct billing code for the service, taking
             769      into account reasonable opinions derived from official published coding definitions, would
             770      result in a lower Medicaid payment or reimbursement.
             771          (12) "Waste" means overutilization of resources or inappropriate payment.
             772          Section 9. Section 63J-4a-201 is enacted to read:
             773     
Part 2. Office Duties and Powers

             774          63J-4a-201. Creation of office -- Inspector general -- Appointment -- Term.
             775          (1) There is created, within the Governor's Office of Planning and Budget, the Office
             776      of Inspector General of Medicaid Services.
             777          (2) The governor shall appoint the inspector general, with the advice and consent of the
             778      Senate.
             779          (3) A person appointed as the inspector general shall:
             780          (a) be a certified public accountant or a certified internal auditor; and
             781          (b) have the following qualifications:
             782          (i) a general knowledge of the type of methodology and controls necessary to audit,
             783      investigate, and identify fraud, waste, and abuse;
             784          (ii) strong management skills;
             785          (iii) extensive knowledge of, and at least seven years experience with, performance


             786      audit methodology;
             787          (iv) the ability to oversee and execute an audit; and
             788          (v) strong interpersonal skills.
             789          (4) The inspector general:
             790          (a) shall serve a term of two years; and
             791          (b) may be removed by the governor, for cause.
             792          (5) If the inspector general is removed for cause, a new inspector general shall be
             793      appointed, with the advice and consent of the Senate, to serve a two-year term.
             794          Section 10. Section 63J-4a-202 is enacted to read:
             795          63J-4a-202. Duties and powers of inspector general and office.
             796          (1) The inspector general shall:
             797          (a) administer, direct, and manage the office;
             798          (b) inspect and monitor the following in relation to the state Medicaid program:
             799          (i) the use and expenditure of federal and state funds;
             800          (ii) the provision of health benefits and other services;
             801          (iii) implementation of, and compliance with, state and federal requirements; and
             802          (iv) records and recordkeeping procedures;
             803          (c) receive reports of potential fraud, waste, or abuse in the state Medicaid program;
             804          (d) investigate and identify potential or actual fraud, waste, or abuse in the state
             805      Medicaid program;
             806          (e) consult with the Centers for Medicaid and Medicare Services and other states to
             807      determine and implement best practices for discovering and eliminating fraud, waste, and
             808      abuse of Medicaid funds;
             809          (f) obtain, develop, and utilize computer algorithms to identify fraud, waste, or abuse
             810      in the state Medicaid program;
             811          (g) work closely with the fraud unit to identify and recover improperly or fraudulently
             812      expended Medicaid funds;
             813          (h) audit, inspect, and evaluate the functioning of the division to ensure that the state


             814      Medicaid program is managed in the most efficient and cost-effective manner possible;
             815          (i) regularly advise the department and the division of an action that should be taken to
             816      ensure that the state Medicaid program is managed in the most efficient and cost-effective
             817      manner possible;
             818          (j) refer potential criminal conduct, relating to Medicaid funds or the state Medicaid
             819      program, to the fraud unit;
             820          (k) determine ways to:
             821          (i) identify, prevent, and reduce fraud, waste, and abuse in the state Medicaid program;
             822      and
             823          (ii) recoup costs, reduce costs, and avoid or minimize increased costs of the state
             824      Medicaid program;
             825          (l) seek recovery of improperly paid Medicaid funds;
             826          (m) track recovery of Medicaid funds by the state;
             827          (n) in accordance with Section 63J-4a-501 :
             828          (i) report on the actions and findings of the inspector general; and
             829          (ii) make recommendations to the Legislature and the governor;
             830          (o) provide training to agencies and employees on identifying potential fraud, waste, or
             831      abuse of Medicaid funds; and
             832          (p) develop and implement principles and standards for the fulfillment of the duties of
             833      the inspector general, based on principles and standards used by:
             834          (i) the Federal Offices of Inspector General;
             835          (ii) the Association of Inspectors General; and
             836          (iii) the United States Government Accountability Office.
             837          (2) The office may conduct a performance or financial audit of:
             838          (a) a state executive branch entity or a local government entity, including an entity
             839      described in Subsection 63J-4a-301 (3), that:
             840          (i) manages or oversees a state Medicaid program; or
             841          (ii) manages or oversees the use or expenditure of state or federal Medicaid funds; or


             842          (b) Medicaid funds received by a person by a grant from, or under contract with, a state
             843      executive branch entity or a local government entity.
             844          (3) The inspector general, or a designee of the inspector general within the office, may
             845      take a sworn statement or administer an oath.
             846          Section 11. Section 63J-4a-203 is enacted to read:
             847          63J-4a-203. Memorandum of understanding with fraud unit.
             848          The inspector general shall enter into a memorandum of understanding with the fraud
             849      unit to:
             850          (1) formalize communication, cooperation, coordination of efforts, and the sharing of
             851      information, on a regular basis, between the office and the fraud unit;
             852          (2) provide for reporting criminal activity discovered by the office to the fraud unit;
             853          (3) ensure that investigations and other actions by the office and the fraud unit do not
             854      conflict; and
             855          (4) provide for the sharing and classification of records between the office and the
             856      fraud unit under the Government Records Access and Management Act.
             857          Section 12. Section 63J-4a-204 is enacted to read:
             858          63J-4a-204. Selection and review of claims.
             859          (1) On an annual basis, the office shall select and review a representative sample of
             860      claims submitted for reimbursement under the state Medicaid program to determine whether
             861      fraud, waste, or abuse occurred.
             862          (2) The office may directly contact the recipient of record for a Medicaid reimbursed
             863      service to determine whether the service for which reimbursement was claimed was actually
             864      provided to the recipient of record.
             865          (3) The office shall generate statistics from the sample described in Subsection (1) to
             866      determine the type of fraud, waste, or abuse that is most advantageous to focus on in future
             867      audits or investigations.
             868          Section 13. Section 63J-4a-205 is enacted to read:
             869          63J-4a-205. Placement of hold on claims for reimbursement -- Injunction.


             870          (1) The inspector general or the inspector general's designee may, without prior notice,
             871      order a hold on the payment of a claim for reimbursement submitted by a claimant if there is
             872      reasonable cause to believe that the claim, or payment of the claim, constitutes fraud, waste, or
             873      abuse, or is otherwise inaccurate.
             874          (2) The office shall, within seven days after the day on which a hold described in
             875      Subsection (1) is ordered, notify the claimant that the hold has been placed.
             876          (3) The inspector general or the inspector general's designee may not maintain a hold
             877      longer than is necessary to determine whether the claim, or payment of the claim, constitutes
             878      fraud, waste, or abuse, or is otherwise inaccurate.
             879          (4) A claimant may, at any time during which a hold is in place, appeal the hold under
             880      Title 63G, Chapter 4, Administrative Procedures Act.
             881          (5) If a claim is approved or denied before a hearing is held under Title 63G, Chapter 4,
             882      Administrative Procedures Act, the appeal shall be dismissed as moot.
             883          (6) The inspector general may request that the attorney general's office seek an
             884      injunction to prevent a person from disposing of an asset that is potentially subject to recovery
             885      by the state to recover funds due to a person's fraud or abuse.
             886          (7) The department and the division shall fully comply with a hold ordered under this
             887      section.
             888          Section 14. Section 63J-4a-206 is enacted to read:
             889          63J-4a-206. Transfer of full-time equivalents to staff office.
             890          The office shall be staffed by transferring from the Office of Internal Audit and
             891      Program Integrity to the office all full-time equivalents for the following positions, as they
             892      existed and were organized within the Office of Internal Audit and Program Integrity on
             893      September 28, 2010, as shown in Appendix B of the Performance Audit of Utah Medicaid
             894      Provider Cost Control, dated December 2010 and published by the Office of the Legislative
             895      Auditor General:
             896          (1) the director of the Office of Internal Audit and Program Integrity;
             897          (2) the executive secretary to the director of the Office of Internal Audit and Program


             898      Integrity;
             899          (3) two positions of program manager of Program Integrity Post Payment Review;
             900          (4) all positions under the positions described in Subsection (3), including:
             901          (a) four RN III positions;
             902          (b) the position of RN III that was vacant on September 28, 2010;
             903          (c) the position of office specialist I that was vacant on September 28, 2010;
             904          (d) doctor (0.2 FTE);
             905          (e) two positions of doctor (0.5 FTE each);
             906          (f) data HPS III;
             907          (g) the position of data HPS II that was vacant on September 28, 2010;
             908          (h) collections HPS II;
             909          (i) PERM Lead;
             910          (j) PERM HPS II; and
             911          (k) PERM HPS II;
             912          (5) the audit manager (performance audit); and
             913          (6) all positions under the position described in Subsection (5), including:
             914          (a) two positions of Lead Auditor;
             915          (b) two positions of Auditor II, including the one that was vacant on September 28,
             916      2010; and
             917          (c) OIAS Support.
             918          Section 15. Section 63J-4a-207 is enacted to read:
             919          63J-4a-207. Filling of transferred positions.
             920          The executive director of the department and the inspector general shall meet to
             921      determine which individuals, if any, who currently hold the positions represented by the
             922      full-time equivalents described in Section 63J-4a-206 , will fill positions in the office. Any
             923      disagreement regarding transferring of personnel shall be resolved by the governor.
             924          Section 16. Section 63J-4a-301 is enacted to read:
             925     
Part 3. Investigation or Audit


             926          63J-4a-301. Access to records -- Retention of designation under Government
             927      Records Access and Management Act.
             928          (1) In order to fulfill the duties described in Section 63J-4a-202 , the office shall have
             929      unrestricted access to all records of state executive branch entities, all local government
             930      entities, and all providers relating, directly or indirectly, to:
             931          (a) the state Medicaid program;
             932          (b) state or federal Medicaid funds;
             933          (c) the provision of Medicaid related services;
             934          (d) the regulation or management of any aspect of the state Medicaid program;
             935          (e) the use or expenditure of state or federal Medicaid funds;
             936          (f) suspected or proven fraud, waste, or abuse of state or federal Medicaid funds;
             937          (g) Medicaid program policies, practices, and procedures;
             938          (h) monitoring of Medicaid services or funds; or
             939          (i) a fatality review of a person who received Medicaid funded services.
             940          (2) The office shall have access to information in any database maintained by the state
             941      or a local government to verify identity, income, employment status, or other factors that affect
             942      eligibility for Medicaid services.
             943          (3) The records described in Subsections (1) and (2) include records held or maintained
             944      by the department, the division, the Department of Human Services, the Department of
             945      Workforce Services, a local health department, a local mental health authority, or a school
             946      district. The records described in Subsection (1) include records held or maintained by a
             947      provider. When conducting an audit of a provider, the office shall, to the extent possible, limit
             948      the records accessed to the scope of the audit.
             949          (4) A record, described in Subsection (1) or (2), that is accessed or copied by the
             950      office:
             951          (a) may be reviewed or copied by the office during normal business hours; and
             952          (b) if it is a government record, shall retain the classification made by the entity
             953      responsible for the record, under Title 63G, Chapter 2, Government Records Access and


             954      Management Act.
             955          (5) Notwithstanding any provision of state law to the contrary, the office shall have the
             956      same access to all records, information, and databases that the department or the division have
             957      access to.
             958          (6) The office shall comply with the requirements of federal law, including the Health
             959      Insurance Portability and Accountability Act of 1996 and 42 C.F.R., Part 2, relating to the
             960      confidentiality of alcohol and drug abuse records, in the office's:
             961          (a) access, review, retention, and use of records; and
             962          (b) use of information included in, or derived from, records.
             963          Section 17. Section 63J-4a-302 is enacted to read:
             964          63J-4a-302. Access to employees -- Cooperating with investigation or audit.
             965          (1) The office shall have access to interview the following persons if the inspector
             966      general determines that the interview may assist the inspector general in fulfilling the duties
             967      described in Section 63J-4a-202 :
             968          (a) a state executive branch official, executive director, director, or employee;
             969          (b) a local government official or employee;
             970          (c) a consultant or contractor of a person described in Subsection (1)(a) or (b); or
             971          (d) a provider or an employee of a provider.
             972          (2) A person described in Subsection (1) and each supervisor of the person shall fully
             973      cooperate with the office by:
             974          (a) providing the office or the inspector general's designee with access to interview the
             975      person;
             976          (b) completely and truthfully answering questions asked by the office or the inspector
             977      general's designee;
             978          (c) providing the records, described in Subsection 63J-4a-301 (1), requested by the
             979      office or the inspector general's designee; and
             980          (d) providing the office or the inspector general's designee with information relating to
             981      the office's investigation or audit.


             982          (3) A person described in Subsection (1)(a) or (b) and each supervisor of the person
             983      shall fully cooperate with the office by:
             984          (a) providing records requested by the office or the inspector general's designee; and
             985          (b) providing the office or the inspector general's designee with information relating to
             986      the office's investigation or audit, including information that is classified as private, controlled,
             987      or protected under Title 63G, Chapter 2, Government Records Access and Management Act.
             988          Section 18. Section 63J-4a-303 is enacted to read:
             989          63J-4a-303. Cooperation and support.
             990          The department, the division, each consultant or contractor of the department or
             991      division, and each provider shall provide its full cooperation and support to the inspector
             992      general and the office in fulfilling the duties of the inspector general and the office.
             993          Section 19. Section 63J-4a-304 is enacted to read:
             994          63J-4a-304. Interference with an investigation or audit prohibited.
             995          No person may:
             996          (1) interfere with or impede an investigation or audit of the office or fraud unit; or
             997          (2) interfere with the office relative to the content of a report, the conclusions reached
             998      in a report, or the manner of disclosing the results and findings of the office.
             999          Section 20. Section 63J-4a-401 is enacted to read:
             1000     
Part 4. Subpoena Power

             1001          63J-4a-401. Subpoena power -- Enforcement.
             1002          (1) The inspector general has the power to issue a subpoena to obtain a record or
             1003      interview a person that the office or inspector general has the right to access under Part 3,
             1004      Investigation or Audit.
             1005          (2) A person who fails to comply with a subpoena issued by the inspector general or
             1006      who refuses to testify regarding a matter upon which the person may be lawfully interrogated:
             1007          (a) is in contempt of the inspector general; and
             1008          (b) upon request by the inspector general, the attorney general shall:
             1009          (i) file a motion for an order to compel obedience to the subpoena with the district


             1010      court;
             1011          (ii) file, with the district court, a motion for an order to show cause why the penalties
             1012      established in Title 78B, Chapter 6, Part 3, Contempt, should not be imposed upon the person
             1013      named in the subpoena for contempt of the inspector general; or
             1014          (iii) pursue other legal remedies against the person.
             1015          (3) Upon receipt of a motion under Subsection (2), the court:
             1016          (a) shall expedite the hearing and decision on the motion; and
             1017          (b) may:
             1018          (i) order the person named in the subpoena to comply with the subpoena; and
             1019          (ii) impose any penalties authorized by Title 78B, Chapter 6, Part 3, Contempt, upon
             1020      the person named in the subpoena for contempt of the inspector general.
             1021          (4) (a) If a subpoena described in this section requires the production of accounts,
             1022      books, papers, documents, or other tangible items, the person or entity to whom it is directed
             1023      may petition a district court to quash or modify the subpoena at or before the time specified in
             1024      the subpoena for compliance.
             1025          (b) The inspector general may respond to a motion to quash or modify the subpoena by
             1026      pursuing any remedy authorized by Subsection (3).
             1027          (c) If the court finds that a subpoena requiring the production of accounts, books,
             1028      papers, documents, or other tangible items is unreasonable or oppressive, the court may quash
             1029      or modify the subpoena.
             1030          (5) Nothing in this section prevents the inspector general from seeking an extraordinary
             1031      writ to remedy contempt of the inspector general.
             1032          (6) Any party aggrieved by a decision of a court under this section may appeal that
             1033      decision directly to the Utah Supreme Court.
             1034          Section 21. Section 63J-4a-501 is enacted to read:
             1035     
Part 5. Reporting

             1036          63J-4a-501. Duty to report potential Medicaid fraud to the office or fraud unit.
             1037          (1) A health care professional, a provider, or a state or local government official or


             1038      employee who becomes aware of fraud, waste, or abuse shall report the fraud, waste, or abuse
             1039      to the office or the fraud unit.
             1040          (2) A person who makes a report under Subsection (1) may request that the person's
             1041      name not be released in connection with the investigation.
             1042          (3) If a request is made under Subsection (2), the person's identity may not be released
             1043      to any person or entity other than the office, the fraud unit, or law enforcement, unless a court
             1044      of competent jurisdiction orders that the person's identity be released.
             1045          Section 22. Section 63J-4a-502 is enacted to read:
             1046          63J-4a-502. Report and recommendations to governor and Executive
             1047      Appropriations Committee.
             1048          (1) The inspector general shall, on an annual basis, prepare a written report on the
             1049      activities of the office for the preceding fiscal year.
             1050          (2) The report shall include:
             1051          (a) non-identifying information, including statistical information, on:
             1052          (i) the items described in Subsection 63J-4a-202 (1)(b) and Section 63J-4a-204 ;
             1053          (ii) action taken by the office and the result of that action;
             1054          (iii) fraud, waste, and abuse in the state Medicaid program;
             1055          (iv) the recovery of fraudulent or improper use of state and federal Medicaid funds;
             1056          (v) measures taken by the state to discover and reduce fraud, waste, and abuse in the
             1057      state Medicaid program;
             1058          (vi) audits conducted by the office; and
             1059          (vii) investigations conducted by the office and the results of those investigations;
             1060          (b) recommendations on action that should be taken by the Legislature or the governor
             1061      to:
             1062          (i) improve the discovery and reduction of fraud, waste, and abuse in the state
             1063      Medicaid program;
             1064          (ii) improve the recovery of fraudulently or improperly used Medicaid funds; and
             1065          (iii) reduce costs and avoid or minimize increased costs in the state Medicaid program;


             1066          (c) recommendations relating to rules, policies, or procedures of a state or local
             1067      government entity; and
             1068          (d) services provided by the state Medicaid program that exceed industry standards.
             1069          (3) The report described in Subsection (1) may not include any information that would
             1070      interfere with or jeopardize an ongoing criminal investigation or other investigation.
             1071          (4) The inspector general shall provide the report described in Subsection (1) to the
             1072      Executive Appropriations Committee of the Legislature and to the governor on or before
             1073      October 1 of each year.
             1074          (5) The inspector general shall present the report described in Subsection (1) to the
             1075      Executive Appropriations Committee of the Legislature before November 30 of each year.
             1076          Section 23. Section 63J-4a-601 is enacted to read:
             1077     
Part 6. Miscellaneous Provisions

             1078          63J-4a-601. Provision of contract services to Office of Inspector General of
             1079      Medicaid Services.
             1080          (1) The division and the assistant attorneys general assigned to the division shall
             1081      provide, without charge, contract review, contract enforcement, and other contract management
             1082      services to the office.
             1083          (2) The division shall ensure that the services described in Subsection (1) are provided
             1084      in an expeditious manner.
             1085          (3) The attorney general shall designate one of the assistant attorneys general assigned
             1086      to the division to give first priority to providing the services described in Subsection (1) to the
             1087      office.
             1088          (4) The office and the division shall enter into a memorandum of understanding in
             1089      order to execute the requirements of this section in an effective and efficient manner.
             1090          Section 24. Section 63J-4a-602 is enacted to read:
             1091          63J-4a-602. Rulemaking authority.
             1092          The office may make rules, pursuant to Title 63G, Chapter 3, Utah Administrative
             1093      Rulemaking Act, that establish policies, procedures, and practices, in accordance with the


             1094      provisions of this chapter, relating to:
             1095          (1) inspecting and monitoring the state Medicaid Program;
             1096          (2) discovering and investigating potential fraud, waste, or abuse in the State Medicaid
             1097      program;
             1098          (3) developing and implementing the principles and standards described in Subsection
             1099      63J-4a-202 (1)(p);
             1100          (4) auditing, inspecting, and evaluating the functioning of the division under
             1101      Subsection 63J-4a-202 (1)(h);
             1102          (5) conducting an audit under Subsection 63J-4a-202 (1)(h) or (2); or
             1103          (6) ordering a hold on the payment of a claim for reimbursement under Section
             1104      63J-4a-205 .
             1105          Section 25. Appropriation.
             1106          Under the terms and conditions of Title 63J, Chapter 1, Budgetary Procedures Act, the
             1107      following sums of money are appropriated from resources not otherwise appropriated out of the
             1108      funds or accounts indicated for the fiscal year beginning July 1, 2011, and ending June 30,
             1109      2012. These are additions to amounts previously appropriated for fiscal year 2012.
             1110          Item 1 To Department of Health - Executive Director's Operations
             1111               From General Fund                             $(694,900)
             1112               From Federal Fund                            $(1,037,000)
             1113               From Revenue Transfers - Within Agency                 $(81,500)
             1114              Schedule of Programs:        
             1115                  Internal Audit and Program Integrity        $(1,813,400)
             1116          Item 2 To Medicaid Mandatory Services
             1117              From General Fund                              $(300,000)
             1118              From Federal Fund                             $(519,100)
             1119              Schedule of Programs:        
             1120                  Other Mandatory Services             $(819,100)
             1121          Item 3 To Office of Inspector General of Medicaid Services


             1122              From General Fund                             $994,900
             1123              From Federal Fund                             $1,556,100
             1124              From Revenue Transfers - Health                     $81,500
             1125              Schedule of Programs:        
             1126                   Office of Inspector General of Medicaid Services $2,632,500
             1127          Section 26. Effective date.
             1128          This bill takes effect on July 1, 2011.


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