§ 26-18-602. Definitions.

     As used in this part:

(1) "Abuse" means:

(a) an action or practice that:

(i) is inconsistent with sound fiscal, business, or medical practices; and

(ii) results, or may result, in unnecessary Medicaid related costs or other medical or hospital assistance costs; or

(b) reckless or negligent upcoding.

(2) "Auditor's Office" means the Office of Internal Audit and Program Integrity, within the department.

(3) "Fraud" means intentional or knowing:

(a) deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, claims, reimbursement, or practice; or

(b) deception or misrepresentation in relation to medical or hospital assistance funds, costs, claims, reimbursement, or practice.

(4) "Medical or hospital assistance" is as defined in Section 26-18-2.

(5) "Upcoding" means assigning an inaccurate billing code for a service that is payable or reimbursable by Medicaid funds, if the correct billing code for the service, taking into account reasonable opinions derived from official published coding definitions, would result in a lower Medicaid payment or reimbursement.

(6) "Waste" means overutilization of resources or inappropriate payment.

Enacted by Chapter 362, 2011 General Session