SB 147 — Office of Inspector General of Medicaid Services Amendments

and {[(f){]}(f) {(e)} } shall adopt administrative rules to establish policies for employees that are substantially similar to the administrative rules adopted by the Division of Human Resource Management.

(7)(7)(a) (a) The executive director shall establish operational performance metrics for the office, including metrics for:

and - 7 - SB0147 compared with SB0147S03 (vi) employee performance.

(8)(8)(a) (a) The executive director shall establish a process for an employee of the office to report the employee's concerns related to:

(i) {act } respond to {address } an employee's concern reported in accordance with the process established under this subsectionSubsection (8) as soon as reasonably possible{,possible; if it is within the executive director's authority under this title to take an action to address the concern} ;

and (ii) submit a written report of the concerns reported according to the process established under this subsectionSubsection (8) to the advisory board at each meeting of the advisory board, including any actions the executive director has taken to address each concern.

(d)- The7 executive- directorS.B. or the inspector general may not take retaliatory action against an employee that reports in good faith a concern in accordance with the process established under this subsection.

147 Enrolled Copy (d) The executive director or the inspector general may not take retaliatory action against an employee that reports in good faith a concern in accordance with the process established under this Subsection (8).

63A-13-202.63A-13-202 .

- 8 - SB0147 compared with SB0147S03 (c) receive reports of potential fraud, waste, or abuse in the [state ]Medicaid program;

(d) investigate and identify potential or actual fraud, waste, or abuse in the [state ]Medicaid] Medicaid program;

(h) audit, investigate, inspect, and evaluate the functioning of the [division for the purpose of making recommendations to the Legislature and the {[} department] {Department of Health and Human Services} Medicaid program to ensure that the [state ]Medicaid program is managed:

(i) identify areas where the Medicaid program can enhance participant health outcomes while- maximizing8 the- prudentEnrolled useCopy ofS.B. public funds;

147 while maximizing the prudent use of public funds;

[(i)] (l) regularly advise the {[department{]}department Department of Health and Human Services} and the division of an action that could be taken to ensure that the [state ]Medicaid program is managed in the most efficient and cost-effective manner possible;

[(j)] (m) refer potential criminal conduct, relating to Medicaid funds or the [state ]Medicaid] Medicaid program, to the fraud unit;

- 9 - SB0147 compared with SB0147S03 [(k)] (n) refer potential criminal conduct, including relevant data from the controlled substance database, relating to Medicaid fraud, to law enforcement in accordance with Title 58, Chapter 37f, Controlled Substance Database Act;

and (ii) balance efforts to reduce costs and avoid or minimize increased costs of the [state ]Medicaid] Medicaid program with the need to encourage robust health care professional and provider participation in the [state ]Medicaid program;

(2)- (a)9 The- officeS.B. may, in fulfilling the duties under Subsection (1), conduct a performance, compliance, or financial audit of:

147 Enrolled Copy (2)(a) The office may, in fulfilling the duties under Subsection (1), conduct a performance, compliance, or financial audit of:

(b)(b)(i) - 10 - SB0147 compared with SB0147S03 (i) The office may not, in fulfilling the duties under Subsection (1), amend the [state[ state ]Medicaid program or change the policies and procedures of the [state ]Medicaid] Medicaid program.

(ii) The office shall identify conflicts between the state Medicaid plan, [department] Department of Health and Human Services administrative rules, Medicaid provider manuals, and Medicaid information bulletins and recommend that the [department][ department] Department of Health and Human Services reconcile inconsistencies.

(3)(3)(a) (a) The office shall, in fulfilling the duties under this section to investigate, discover, and recover fraud, waste, and abuse in the Medicaid program, apply the state Medicaid plan, [department] Department of Health and Human Services administrative rules, Medicaid provider manuals, and Medicaid information bulletins in- effect10 at- theEnrolled timeCopy theS.B. medical services were provided.

147 in effect at the time the medical services were provided.

63A-13-204.63A-13-204 .

(1)(1)(a) - 11 - SB0147 compared with SB0147S03 (a) The office shall periodically select and review a representative sample of claims submitted for reimbursement under the [state ]Medicaid program to determine whether fraud, waste, or abuse occurred.

and (B)- over11 a- threeS.B. year period of time;

147 Enrolled Copy (B) over a three year period of time;

(4)(4)(a) - 12 - SB0147 compared with SB0147S03 (a) If the office, or a contractor on behalf of the [department] Department of Health and Human Services:

(i) intends to implement the use of extrapolation as a method of auditing claims, the [department][ department] office or the Department of Health and Human Services shall, prior to adopting the extrapolation method of auditing, report its intent to use extrapolation:

(b)(b)(i) (i) If extrapolation is used under this section, a provider may, at the provider's option, appeal the results of the audit based on:

63A-13-205.63A-13-205 .

(3)- The12 inspector- generalEnrolled orCopy theS.B. inspector general's designee may not maintain a hold longer than is necessary to determine whether the claim, or payment of the claim, constitutes fraud, waste, or abuse, or is otherwise inaccurate.

147 (3) The inspector general or the inspector general's designee may not maintain a hold longer than is necessary to determine whether the claim, or payment of the claim, constitutes fraud, waste, or abuse, or is otherwise inaccurate.

- 13 - SB0147 compared with SB0147S03 (5) If a claim is approved or denied before a hearing is held under Title 63G, Chapter 4, Administrative Procedures Act, the appeal shall be dismissed as moot.

63A-13-301.63A-13-301 .

(3)(3)(a) (a) The records described in Subsections (1) and (2) include records held or maintained by the department, the division, the Department of Health and Human Services, the Department of Workforce Services, a local health department, a local mental- health13 authority,- orS.B. a school district.

147 Enrolled Copy mental health authority, or a school district.

- 14 - SB0147 compared with SB0147S03 (b) When conducting an audit of a provider, the office shall, to the extent possible, limit the records accessed to the scope of the audit.

63A-13-303.63A-13-303 .

The [department] Department of Health and Human Services, the division, each consultant or contractor of the [department] Department of Health and Human Services or division,- and14 each- providerEnrolled shallCopy provideS.B. its full cooperation and support to the inspector general and the office in fulfilling the duties of the inspector general and the office.

147 division, and each provider shall provide its full cooperation and support to the inspector general and the office in fulfilling the duties of the inspector general and the office.

-63A-13-502 15. - SB0147 compared with SB0147S03 63A-13-502.

(v) measures taken by the state to discover and reduce fraud, waste, and abuse in the [state[ state ]Medicaid program;

(b) recommendations on action that should be taken by the Legislature or the governor to:- 15 - S.B.

(i)147 improveEnrolled theCopy discoveryto: and reduction of fraud, waste, and abuse in the [state ]Medicaid program;

(i) improve the discovery and reduction of fraud, waste, and abuse in the [state ] Medicaid program;

- 16 - SB0147 compared with SB0147S03 (3) The report described in Subsection (1) may not include any information that would interfere with or jeopardize an ongoing criminal investigation or other investigation.

63A-13-602.63A-13-602 .

(3) developing and implementing the principles and standards described in Subsection [63A-13-202(1)[ (q)]63A-13-202(1)(q)] 63A-13-202(1)(t);

(4) auditing, investigating, inspecting, and evaluating the functioning of the division[division] Medicaid program under Subsection 63A-13-202(1)(h);

(5) conducting [an] a performance, compliance, or financial audit under Subsection 63A-13-202(1)(h)- or16 (2);- Enrolled Copy S.B.

147 63A-13-202(1)(h) or (2);

Section 1263A-13-701 is enacted to read:

63A-13-701.Part 7.

Office of {the } Inspector General of Medicaid Services Advisory Board.Board 63A-13-701 .

7.Office of Inspector General of Medicaid Services Advisory Board.

Office of {the } Inspector General of Medicaid Services Advisory Board - 17 - SB0147 compared with SB0147S03 (1) In consultation with the inspector general, the executive director or the executive director's designee shall create an advisory board known as the "Office of {the } Inspector General of Medicaid Services Advisory Board," to:

(b) make recommendations to the office and the {department } Department of Government Operations regarding prioritization of the office's financial audit activities;

(c) {make recommendations to the Office of the Legislative Auditor General regarding audits related to } review employee concerns reported in accordance with the process the executive director establishes under Subsection 63A-13-201(8);

{and} (d) make recommendations to the inspector general, the executive director, and the Legislature for improving the office's operations{.}operations; ;

(2) The {department } Department of Government Operations shall make rules to establish:

(a) composition of the advisory board, whichshallwhich shall include:

{(i) {may include :} } {(A) {members of the House of Representatives appointed by the speaker of the House of Representatives;} } (i) the executive director of the Department of Health and Human Services or the executive director's designee;

and (B){(ii)}(ii) {members of } the {Senate } state Medicaid director appointed {by the president of the Senate} under Section 26B-3-103;

{and}(b) {(C)the {othermethod membersof asselection determinedor byappointment of advisory board members, including for the department;selection of an advisory board chair;

and} } {(ii) {shall include the legislative auditor general or the legislative auditor general's designee;} } (b) the method of selection or appointment of advisory board members, including for the selection of an advisory board chair;

- 18 - SB0147 compared with SB0147S03 (3) Members of the advisory board {not described in Subsection(2)(a) } shall be qualified by training, education, and experience.

and (b) in addition to the meetings described in Subsection (4)(a), at the request of the executive- director.17 - S.B.

147 Enrolled Copy executive director.

(5){(6)}(6) The advisory board is subject to Title 52, Chapter 4, Open and Public Meetings Act.

{(6)(7) } (a){(7)} A member of the advisory board {who is not a legislator } may not receive compensation or benefits for the member's service, but may receive per diem and travel expenses in accordance with:

(i){(a)}(a) Section 63A-3-106;

(ii)(b)(b) Section 63A-3-107;

and (iii)(c)(c) rules made by the Division of Finance in accordance with Sections 63A-3-106 and 63A-3-107.

{(b) {Compensation and expenses of a member of the advisory board who is a legislator are governed by Section 36-2-2 and Legislative Joint Rules, Title 5, Legislative Compensation and Expenses.} } Section 13.

63H-9-101.63H-9-101 .

(3)(3)(a) (a) "Independent entity" means an entity that:

and - 19 - SB0147 compared with SB0147S03 (iv) is not under the direct supervisory control of the governor.

or (viii) an elective constitutional office, including the state auditor, the state treasurer, and- the18 attorney- general.Enrolled Copy S.B.

147 and the attorney general.

[(ix)] (viii) School and Institutional Trust Lands Administration created in Section [53D-1-201][ 53D-1-201] 53C-1-201;

and - 20 - SB0147 compared with SB0147S03 [(xix)] (xviii) [Utah ]State Fair Park Authority created in Section 11-68-201.

63I-1-263.63I-1-263 .

[(3)]- (6)19 Title- 63C,S.B. Chapter 25, State Finance Review Commission, is repealed July 1, 2027.

147 Enrolled Copy [(3)] (6) Title 63C, Chapter 25, State Finance Review Commission, is repealed July 1, 2027.

- 21 - SB0147 compared with SB0147S03 [(16)] (19) Title 63M, Chapter 11, Utah Commission on Aging, is repealed July 1, 2026.

[(23)] (26) Section 63N-4-804, Rural Opportunity Advisory Committee, is repealed July 1, 2027.- 20 - Enrolled Copy S.B.

147 2027.

Effective date.

3-3-26 2:50 PM - 2221 -