Alaska Administrative Code
Title 7 - Health and Social Services
Part 8 - Medicaid Coverage and Payment
Chapter 160 - Medicaid Program; General Provisions
Article 1 - Program Integrity and Quality Assurance
7 AAC 160.115 - Duty of a provider to identify and repay self-identified overpayments

Universal Citation: 7 AK Admin Code 160.115

Current through November 28, 2024

(a) An enrolled provider who bills the department for services rendered during a calendar year shall conduct, once every two years, a review or audit of a statistically valid random sample of claims submitted to the department for reimbursement, unless the provider is being audited under AS 47.05.200(a). The universe of claims from which the random sample is drawn must be all claims that are billed with dates of service during the calendar year for the provider and that may be identified at the taxpayer identification level. As part of the self-review or self-audit, a provider shall establish appropriate corrective actions for any deficiencies identified.

(b) A biennial review or audit conducted under this section shall be conducted not earlier than one year following the end of the calendar year to allow for timely filing of all claims.

(c) The provider may use any widely accepted statistical software, such as RAT-STATS, developed by the United States Department of Health and Human Services, Office of Inspector General, to assist in sample size determination, and sample selection, using a minimum of a 90- percent confidence interval.

(d) If a provider identifies overpayments through the biennial review or audit, the provider shall report each overpayment to the department not later than 10 business days after identification of that overpayment. Overpayment reports shall be submitted to the Department of Health and Social Services, Office of the Commissioner, Medicaid Program Integrity. In this subsection, "business day" means a day other than Saturday, Sunday, or a legal holiday under AS 44.12.010.

(e) A provider who was reimbursed

(1) $30,000 or greater for services during the year shall submit a report to the department detailing the claims audited or reviewed together with the results of that review or audit;

(2) $10,000 or greater but less than $30,000 is not required to submit the report to the department but must have the report available for review by the department;

(3) less than $10,000 is not required to produce a report but shall have an attestation form on file and available for review by the department.

(f) The reimbursement values referenced in (e) of this section are based upon the reimbursement values reported in each United States Internal Revenue Service form 1099 that the department issues to the provider by calendar year.

(g) The report or attestation required under this section must be made in writing on a form approved by the department and submitted, if required, to the Department of Health and Social Services, Office of the Commissioner, Medicaid Program Integrity. The report must include

(1) the method used to sample the claims;

(2) the sampled claims Medicaid assigned transaction control number (TCN);

(3) the outcome of the individual claim audit;

(4) the identified amount of overpayment back to the department; and

(5) if appropriate, a corrective action plan.

(h) A provider shall retain all audit documents, reports, and attestations created as a result of the review for at least seven calendar years following completion.

(i) Not later than 60 days after identification of the overpayment, the provider shall repay the department unless the provider has a repayment agreement with the department. The department may, in the repayment agreement, authorize repayment through one of the following means:

(1) a lump sum payable not later than two months after the date of the discovery of the overpayment;

(2) a payment plan not to exceed two years in length; the department may extend the payment plan beyond two years based on the following factors:
(A) the provider's history of compliance with the Medicaid program generally, including prior payment agreements;

(B) the amount of the overpayment;

(C) the amount of revenue the provider is receiving from Medicaid;

(D) any other factors that would impact repayment, such as type of services being provided;

(3) by offsetting future billings by the provider; if a provider chooses to offset future billings, the amount offset must be repaid not later than two years from the date of the agreement.

(j) If a provider defaults on a repayment under (i) of this section, the department may require immediate payment of the total amount due, If a provider defaults on paying the total amount, the provider is subject to sanctions under 7 AAC 105.400 - 7 AAC 105.490. Sanctions may include termination from the Medicaid program in accordance with 7 AAC 105.410.

(k) Under this section, an overpayment is identified when the provider has, through the exercise of reasonable diligence, determined that the provider has received an overpayment and quantified the amount of the overpayment.

(l) The department may review the results of a provider-conducted self-review for accuracy. If the provider does not provide an opportunity for department review under this subsection or obstructs the review, or if the department determines that the provider's self-review is inaccurate, the department may impose sanctions under 7 AAC 105.400 - 7 AAC 105.490.

(m) For purposes of this section,

(1) "default" means any default that results in written notice from the department;

(2) "immediate repayment" means a payment this is made not later than 30 days after written notice is provided under (m)(1) of this section.

For information regarding the conduct of a self-audit, please refer to the CMS self-audit toolkit, Conducting a Self-Audit: A Guide for Physicians and Other Health Care Professionals, February 2016. The toolkit may be obtained at the following website: https://www.cms.gov/Medicare-Medicaid-Coordination-Fraud-Prevention/Medicaid-Integrity-Education/audit-toolkit.html. The address of the Department of Health and Social Services, Office of the Commissioner, Medicaid Program Integrity is 3601 C Street. Anchorage. Alaska 99503.

Authority:AS 47.05.010

AS 47.05.200

AS 47.05.235

AS 47.07.030

AS 47.07.040

AS 47.07.074

Disclaimer: These regulations may not be the most recent version. Alaska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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