{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-319.1.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-319.1.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-319.1.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-319.1.html"}],"law_id":54400,"edition_id":1,"section_id":54400,"structure_id":13438,"section_number":"32.1-319.1","catch_line":"Department to establish pilot program to use data analytics to mitigate risk of improper payments","history":"2017, c. 750; 2019, c. 422.","full_text":"A\n\nThe Department shall conduct a pilot program to develop and implement means to mitigate the risk of improper payments to providers of services furnished under the state plan for medical assistance and all applicable waivers. The pilot program shall include the use of predictive modeling, provider profiling, trend analysis, and other analytics to identify providers with a high likelihood of fraud, abuse, or error and prevent payments on potentially fraudulent or erroneous claims from being made until such claims have been validated.B\n\nThe Department may enter into a contract or agreement with a vendor for the operation of the pilot program to mitigate the risk of improper payments to providers of services furnished under the state plan for medical assistance and all applicable waivers required by this section. However, selection of a vendor shall be dependent on the demonstration of a proof of concept, prior to entering into a contract or agreement.","order_by":null,"text":{"0":{"id":199699,"text":"The Department shall conduct a pilot program to develop and implement means to mitigate the risk of improper payments to providers of services furnished under the state plan for medical assistance and all applicable waivers. The pilot program shall include the use of predictive modeling, provider profiling, trend analysis, and other analytics to identify providers with a high likelihood of fraud, abuse, or error and prevent payments on potentially fraudulent or erroneous claims from being made until such claims have been validated.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":199700,"text":"The Department may enter into a contract or agreement with a vendor for the operation of the pilot program to mitigate the risk of improper payments to providers of services furnished under the state plan for medical assistance and all applicable waivers required by this section. However, selection of a vendor shall be dependent on the demonstration of a proof of concept, prior to entering into a contract or agreement.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A"}},"ancestry":[{"id":13438,"edition_id":1,"name":"In General","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":13437,"metadata":{},"date_created":"2026-06-26 03:44:53","date_modified":"2026-06-26 03:44:53","permalink":{"id":204701,"object_type":"structure","relational_id":13438,"identifier":"1","token":"32.1\/9\/1","url":"\/32.1\/9\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":13437,"edition_id":1,"name":"Regulation of Medical Assistance","identifier":"9","label":"chapter","depth":2,"order_by":1,"parent_id":12727,"metadata":{},"date_created":"2026-06-26 03:44:53","date_modified":"2026-06-26 03:44:53","permalink":{"id":204699,"object_type":"structure","relational_id":13437,"identifier":"9","token":"32.1\/9","url":"\/32.1\/9\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12727,"edition_id":1,"name":"Health","identifier":"32.1","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:50","date_modified":"2026-06-26 03:43:50","permalink":{"id":201099,"object_type":"structure","relational_id":12727,"identifier":"32.1","token":"32.1","url":"\/32.1\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":85954,"structure_id":13438,"section_number":"32.1-310","catch_line":"Declaration of purpose; authority to audit records; authority to review complaints of abuse or neglect","url":"\/32.1-310\/","token":"32.1\/9\/1\/32.1-310","metadata":false},{"id":70907,"structure_id":13438,"section_number":"32.1-311","catch_line":"Repealed","url":"\/32.1-311\/","token":"32.1\/9\/1\/32.1-311","metadata":false},{"id":54506,"structure_id":13438,"section_number":"32.1-312","catch_line":"Fraudulently obtaining excess or attempting to obtain excess benefits or payments; penalty","url":"\/32.1-312\/","token":"32.1\/9\/1\/32.1-312","metadata":false},{"id":78625,"structure_id":13438,"section_number":"32.1-313","catch_line":"Liability for excess benefits or payments obtained without intent to violate chapter","url":"\/32.1-313\/","token":"32.1\/9\/1\/32.1-313","metadata":false},{"id":63947,"structure_id":13438,"section_number":"32.1-314","catch_line":"False statement or representation in applications for payment or for use in determining rights to payment; concealment of facts; penalty","url":"\/32.1-314\/","token":"32.1\/9\/1\/32.1-314","metadata":false},{"id":70472,"structure_id":13438,"section_number":"32.1-315","catch_line":"Solicitation or receipt of remuneration for certain services; offer or payment of remuneration for inducement of such services; penalty","url":"\/32.1-315\/","token":"32.1\/9\/1\/32.1-315","metadata":false},{"id":65811,"structure_id":13438,"section_number":"32.1-316","catch_line":"False statement or representation as to conditions or operations of institution or facility; penalty","url":"\/32.1-316\/","token":"32.1\/9\/1\/32.1-316","metadata":false},{"id":63268,"structure_id":13438,"section_number":"32.1-317","catch_line":"Collecting excess payment for services; charging, soliciting, accepting or receiving certain consideration as precondition for admittance to facility or requirement for continued stay; penalty","url":"\/32.1-317\/","token":"32.1\/9\/1\/32.1-317","metadata":false},{"id":69423,"structure_id":13438,"section_number":"32.1-318","catch_line":"Knowing failure to deposit, transfer or maintain patient trust funds in separate account; penalty","url":"\/32.1-318\/","token":"32.1\/9\/1\/32.1-318","metadata":false},{"id":71136,"structure_id":13438,"section_number":"32.1-319","catch_line":"Written verification of application, statement or form; penalty for false or misleading information","url":"\/32.1-319\/","token":"32.1\/9\/1\/32.1-319","metadata":false},{"id":54400,"structure_id":13438,"section_number":"32.1-319.1","catch_line":"Department to establish pilot program to use data analytics to mitigate risk of improper payments","url":"\/32.1-319.1\/","token":"32.1\/9\/1\/32.1-319.1","metadata":false},{"id":73899,"structure_id":13438,"section_number":"32.1-320","catch_line":"Duties of Attorney General; medical services providers audit and investigation unit","url":"\/32.1-320\/","token":"32.1\/9\/1\/32.1-320","metadata":false},{"id":60362,"structure_id":13438,"section_number":"32.1-320.1","catch_line":"Powers and duties of sworn unit investigators","url":"\/32.1-320.1\/","token":"32.1\/9\/1\/32.1-320.1","metadata":false},{"id":81672,"structure_id":13438,"section_number":"32.1-321","catch_line":"Prosecution of cases","url":"\/32.1-321\/","token":"32.1\/9\/1\/32.1-321","metadata":false},{"id":72394,"structure_id":13438,"section_number":"32.1-321.01","catch_line":"Exemptions from disclosure","url":"\/32.1-321.01\/","token":"32.1\/9\/1\/32.1-321.01","metadata":false}],"previous_section":{"id":71136,"structure_id":13438,"section_number":"32.1-319","catch_line":"Written verification of application, statement or form; penalty for false or misleading information","url":"\/32.1-319\/","token":"32.1\/9\/1\/32.1-319","metadata":false},"next_section":{"id":73899,"structure_id":13438,"section_number":"32.1-320","catch_line":"Duties of Attorney General; medical services providers audit and investigation unit","url":"\/32.1-320\/","token":"32.1\/9\/1\/32.1-320","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/32.1-319.1\/","history_text":"

This law was first created in 2017. The record of its establishment is cataloged in chapter 750<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. It has been modified 1 time. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. That modification is as follows: in 2019, chapter 422<\/a>.<\/p>","references":[{"id":84033,"section_number":"2.2-4348","catch_line":"Exemptions","order_by":null,"url":"\/2.2-4348\/"}],"refers_to":false,"permalink":{"id":204743,"object_type":"law","relational_id":54400,"identifier":"32.1-319.1","token":"32.1\/9\/1\/32.1-319.1","url":"\/32.1-319.1\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-319.1\/","token":"32.1\/9\/1\/32.1-319.1","dublin_core":{"Title":"Department to establish pilot program to use data analytics to mitigate risk of improper payments","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-319.1","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> The Department<\/span> shall conduct a pilot program to develop and implement means to mitigate the risk of improper payments to providers of services furnished under the state plan for medical assistance and all applicable waivers<\/span>. The pilot program shall include the use of predictive modeling, provider profiling, trend analysis, and other analytics to identify providers with a high likelihood of fraud<\/span>, abuse, or error and prevent payments on potentially fraudulent or erroneous claims from being made until such claims have been validated. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> The Department<\/span> may enter into a contract<\/span> or agreement with a vendor for the operation of the pilot program to mitigate the risk of improper payments to providers of services furnished under the state plan for medical assistance and all applicable waivers<\/span> required by this section. However, selection of a vendor shall be dependent on the demonstration of a proof of concept, prior to entering into a contract<\/span> or agreement. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nDEPARTMENT TO ESTABLISH PILOT PROGRAM TO USE DATA ANALYTICS TO MITIGATE RISK OF\nIMPROPER PAYMENTS (\u00a7 32.1-319.1)\n\nA. The Department shall conduct a pilot program to develop and implement means\nto mitigate the risk of improper payments to providers of services furnished\nunder the state plan for medical assistance and all applicable waivers. The\npilot program shall include the use of predictive modeling, provider profiling,\ntrend analysis, and other analytics to identify providers with a high likelihood\nof fraud, abuse, or error and prevent payments on potentially fraudulent or\nerroneous claims from being made until such claims have been validated.\n\nB. The Department may enter into a contract or agreement with a vendor for the\noperation of the pilot program to mitigate the risk of improper payments to\nproviders of services furnished under the state plan for medical assistance and\nall applicable waivers required by this section. However, selection of a vendor\nshall be dependent on the demonstration of a proof of concept, prior to entering\ninto a contract or agreement.\n\nHISTORY: 2017, c. 750; 2019, c. 422.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}