A. Notwithstanding any other provision of law to the contrary, the department shall require that its recovery audit contractor perform all of the following functions and tasks:
(1)Review claims within three years of the date of their initial payment.
(2)Send a determination letter concluding an audit within sixty days of receipt of all requested materials from a provider.
(3)Furnish in any records request to a provider adequate information for the provider to identify the patient, including but not limited to claim number, medical record number, patient name, and service dates.
(4)Exclude all of the following from its scope of review:
(a)Claims processed or paid within ninety days of implementation of any Medicaid managed care program.
(b)Claims processed or paid through a capitated
Free access — add to your briefcase to read the full text and ask questions with AI
A. Notwithstanding any other provision of law to the contrary, the department shall require that its recovery audit contractor perform all of the following functions and tasks:
(1) Review claims within three years of the date of their initial payment.
(2) Send a determination letter concluding an audit within sixty days of receipt of all requested materials from a provider.
(3) Furnish in any records request to a provider adequate information for the provider to identify the patient, including but not limited to claim number, medical record number, patient name, and service dates.
(4) Exclude all of the following from its scope of review:
(a) Claims processed or paid within ninety days of implementation of any Medicaid managed care program.
(b) Claims processed or paid through a capitated Medicaid managed care program.
(c) Medical necessity reviews in which the provider has obtained prior authorization for the service.
(5) Develop and implement a process to ensure that providers receive or retain the appropriate reimbursement amount for claims within the lookback period in which the contractor determines that services delivered have been improperly billed, but were reasonable and necessary.
(6)(a) Prohibit the recoupment of overpayments by the contractor until all informal and formal appeals processes have been completed.
(b) Nothing in this Paragraph shall apply to claims that the contractor suspects to be fraudulent.
(7) Refer claims it suspects to be fraudulent directly to the department for investigation.
(8) Provide a detailed explanation in writing to a provider for any adverse determination that would result in partial or full recoupment of a payment to the provider. The written notification provided for in this Paragraph shall include, at minimum, all of the following:
(a) The reason for the adverse determination.
(b) The specific medical criteria on which the adverse determination was based.
(c) An explanation of the provider's appeal rights.
(d) If applicable, an explanation of the appropriate reimbursement determined in accordance with the provisions of Paragraph (5) of this Subsection.
(9)(a) Limit records requests in a ninety-day period to not more than one percent of the number of claims filed by the provider for the specific service being reviewed in the previous state fiscal year, not to exceed two hundred records.
(b) The contractor shall allow a provider no less than forty-five days to comply with and respond to a record request.
(c) If the contractor can demonstrate a significant provider error rate relative to an audit of records, the contractor may make a request to the department to initiate an additional records request relative to the issue being reviewed for the purposes of further review and validation. The contractor shall not make the request to the department until the time period for the informal appeals process has expired, and the provider shall be given the opportunity to contest to the department the second records request.
(10) Utilize provider self-audits only if mutually agreed to by the contractor and provider.
(11) Schedule any onsite audits of a low-risk provider with advance notice of not less than ten business days and make a good-faith effort to establish a mutually agreed upon date and time.
(12) Publish on its Internet website department-approved issues for review. Information concerning such issues shall include, at minimum, the name and description of the issue, type of provider, review period, and applicable policy relative to the review.
(13) On a semiannual basis, develop, implement, and publish on its Internet website metrics related to its performance. Such metrics shall include but not be limited to the following:
(a) The number and type of issues reviewed.
(b) The number of medical records requested.
(c) The number of overpayments and underpayments identified by the contractor.
(d) The aggregate dollar amounts associated with identified overpayments and underpayments.
(e) The duration of audits from initiation to time of completion.
(f) The number of adverse determinations and the overturn rates of those determinations at each stage of the informal and formal appeal process.
(g) The number of informal and formal appeals filed by providers, categorized by disposition status.
(h) The contractor's compensation structure and dollar amount of compensation.
(14) Post on its Internet website its contract with the department for recovery audit services.
(15)(a) Perform a semiannual review of recovery audit issues and identify any potential opportunities for improvement and correction of medical assistance program policies, procedures, and infrastructure that would result in proactive and efficient minimization of improper payments.
(b) The contractor shall submit the reviews provided for in this Paragraph to the department and publish such reviews on its Internet website.
(16) At least semiannually, perform educational and training programs for providers that encompass all of the following:
(a) A recapitulation of audit results, common issues and problems, and mistakes identified through audits and reviews.
(b) A discussion of opportunities for improvement in provider performance with respect to claims billing and documentation.
(17)(a) Allow providers to submit in electronic format the records requested in association with an audit.
(b) If a provider must reproduce records manually because no electronic format is available, or because the contractor requests a nonelectronic format, the contractor shall make reasonable efforts to reimburse to the provider the cost of medical records reproduction consistent with the provisions of 42 CFR 476.78.
B. In any contract between the department and a recovery audit contractor, the payment or fee provided to the contractor for identification of Medicaid provider overpayments shall be equal to that provided for identification of Medicaid provider underpayments.