STATE OF NEW JERSEY
216th LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2014 SESSION
Sponsored by:
Assemblyman ANGEL FUENTES
District 5 (Camden and Gloucester)
Assemblywoman ANNETTE QUIJANO
District 20 (Union)
Assemblyman TIMOTHY J. EUSTACE
District 38 (Bergen and Passaic)
SYNOPSIS
Requires cost-saving reforms to administration of correctional health care.
CURRENT VERSION OF TEXT
Introduced Pending Technical Review by Legislative Counsel
An Act concerning correctional health care and supplementing Title 30 of the Revised Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. The Legislature finds and declares that other states have saved millions of dollars by implementing solutions to eliminate and recover correctional health care overpayments. Similarly, other states have significantly reduced correctional health care costs by billing Medicaid for eligible inpatient health care costs. Therefore, it is the intent of the Legislature to implement automated payment detection, prevention, and recovery solutions to reduce correctional health care overpayments and to assure that Medicaid is billed for eligible inpatient hospital and professional services.
2. As used in this act:
"Department" means the Department of Corrections.
"Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).
3. a. The department shall implement state-of-the-art clinical code editing technology solutions to further automate claims resolution and enhance cost containment through improved claim accuracy and appropriate code correction. The technology shall identify and prevent errors and potential overbilling based on widely accepted and referenced protocols such as those used by the American Medical Association and the Centers for Medicare & Medicaid Services. The edits shall be applied automatically before claims are adjudicated to speed processing and reduce the number of pended or rejected claims and help ensure a smoother, more consistent, and more open adjudication process and fewer delays in provider reimbursement.
b. The department shall implement correctional health care claims audit and recovery services to identify improper payments due to non-fraudulent issues, audit claims, obtain provider sign-off on the audit results, and recover validated overpayments. Post-payment reviews shall ensure that the diagnoses and procedure codes are accurate and valid based on the supporting physician documentation within the medical records. Core categories of reviews may include: coding compliance Diagnosis-Related Group (DRG) reviews, transfers, readmissions, cost outlier reviews, outpatient 72-hour rule reviews, payment errors, billing errors, or others.
c. The department shall implement automated payment detection, prevention, and recovery solutions to assure that Medicaid is billed for eligible inpatient hospital and professional services.
4. The department shall contract with an outside entity for the provision of the services specified by section 3 of this act. To the extent possible, technology services used in carrying out this act shall be secured using the savings generated by the program, whereby the State's only direct cost would be funded through the actual savings achieved. Further, to enable this model, reimbursement to the contractor may be contracted on the basis of a percentage of achieved savings model, a per beneficiary per month model, a per transaction model, a case-rate model, or any blended model of the aforementioned methodologies. Reimbursement models with the contractor may also include performance guarantees of the contractor to ensure that savings identified exceed program costs.
5. This act shall take effect on the first day of the seventh month next following the date of enactment, except that the Commissioner of Corrections may take such anticipatory administrative action in advance thereof as may be necessary for the implementation of this act.
STATEMENT
This bill requires the Department of Corrections to contract with an outside entity to implement a set of reforms to the State's correctional health care system in order to reduce State costs.
Specifically, the bill requires implementation of: (1) state-of-the-art clinical code editing technology solutions to further automate claims resolution and enhance cost containment through improved claim accuracy and appropriate code correction; (2) claims audit and recovery services to identify improper payments due to non-fraudulent issues, audit claims, obtain provider sign-off on the audit results, and recover validated overpayments; and (3) automated payment detection, prevention, and recovery solutions to assure that Medicaid is billed for eligible inpatient hospital and professional services.
The bill provides that, to the extent possible, technology services used in carrying out the bill must be secured using the savings generated by the program, whereby the State's only direct cost would be funded through the actual savings achieved.
The bill takes effect on the first day of the seventh month following the date of enactment, but permits the Commissioner of Corrections to take anticipatory administrative action in as necessary for its implementation.