2015 Oregon Revised Statutes
Volume : 10 - Highways, Military, Juvenile Code, Human Services
Chapter 413 - Oregon Health Authority
Section 413.151 - Setoff of liquidated and delinquent debts.

Note: See note under 413.105.

Note: Section 6, chapter 24, Oregon Laws 2014, provides:

Sec. 6. Waste, fraud and abuse detection systems. (1) Not later than September 1, 2014, the Oregon Health Authority shall issue a request for information seeking input from potential contractors on the capabilities that the authority lacks, functions the authority is not performing and the costs of implementing:

(a) Advanced predictive modeling and analytics technologies integrated into the medical assistance claims processing system to provide a comprehensive and accurate view across all providers, recipients and geographic regions within the state medical assistance program that will enable the authority to:

(A) Identify and analyze billing or utilization patterns that represent a high risk of fraudulent activity before payment is made in order to minimize disruptions in claims processing operations and speed the resolution of medical assistance claims;

(B) Prioritize transactions identified as likely for potential waste, fraud or abuse to receive additional review before payment is made;

(C) Obtain outcome information from adjudicated claims to allow for refinement and enhancement of the predictive analytics technologies based on historical data and algorithms within the system; and

(D) Prevent the payment of claims for reimbursement that have been identified as potentially wasteful, fraudulent or abusive until the claims have been automatically verified as valid.

(b) Provider and recipient data verification and screening technologies that use publicly available records for the purpose of automating reviews and identifying and preventing inappropriate payments by:

(A) Identifying associations within and between providers and provider groups that indicate potential collusive fraudulent activity;

(B) Identifying recipient attributes that indicate potential ineligibility; and

(C) Using fraud investigation services that combine retrospective claims analysis and prospective waste, fraud or abuse detection techniques. These services shall include analysis of historical claims data, medical records, suspect provider databases and high-risk identification lists, as well as direct patient and provider interviews. Emphasis shall be placed on providing education to providers and ensuring that providers have the opportunity to review and correct any problems identified prior to adjudication.

(2) The authority may use the results of the request for information to create a formal request for proposals to implement the systems and technologies identified in this section if the authority determines that:

(a) Savings will be generated by preventing fraud, waste and abuse;

(b) The systems and technologies can be integrated into the authority’s current medical assistance claims processing operations without incurring additional costs to the state; and

(c) The reviews described in subsection (1)(b) of this section are unlikely to delay or improperly deny payment of valid claims.

[2014 c.24 §6]