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4000-0301 - MassHealth Auditing and Utilization Reviews
| Account | Description | FY 2014 GAA |
FY 2015 House 2 |
|---|---|---|---|
| 4000-0301 | MassHealth Auditing and Utilization Reviews For the costs of MassHealth provider and member audit and utilization review activities including eligibility verification, disability evaluations, provider financial and clinical audits and other initiatives intended to enhance program integrity; provided, that no expenditures shall be made from this item that are not federally reimbursable; provided further, that notwithstanding any general or special law to the contrary, the state Medicaid office is hereby authorized to conduct a trial to determine the effectiveness of various fraud management tools to identify potential fraud at claims submission and validation in order to reduce Medicaid fraud prior to payment; provided further, that the state Medicaid office may employ strategies to improve systems for detection and may allow for the use of external data sources; provided further, that any such trial may test innovative technologies to improve Medicaid fraud detection and evaluate the efficacy of, among other things, a real-time model to identify and investigate potential Medicaid fraud cases prior to payment; and provided further, that the Medicaid office may use actual claims data, in accordance with federal law, to identify specific suspicious provider billing patterns, document the results of any potential fraud findings and estimate anticipated savings and benefits to the commonwealth associated with such a fraud detection system |
4,416,519 | 4,425,793 |
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