Current through March 20, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 4-6-10; IC 4-21.5-3; IC 12-15-1; IC 12-15-6-5;
IC 12-15-13-3.5; IC 12-15-13-4; IC 12-15-21-3; IC 12-15-23-2
Sec. 9.
(a) Under IC
12-15-21-3(5) and IC 12-15-21-3(7), the office may recover payment from any
provider for services rendered to an individual, or claimed to be rendered to
an individual, if the office, after investigation or audit, finds that:
(1) the services paid for cannot be
documented by the provider as required by section 2 of this rule;
(2) the amount paid for such services has
been paid from other sources or is subject to third party liability;
(3) the services were provided to a person
other than the person in whose name the claim was made and paid;
(4) the service reimbursed was provided to a
person who was not eligible for Medicaid at the time of the provision of the
service;
(5) the paid claim arises
out of any act or practice prohibited by law or by rules of the
office;
(6) the overpayment
resulted from:
(A) an inaccurate description
of services or an inaccurate usage of procedure codes;
(B) the provider's itemization of services
rather than submission of one (1) billing for a related group of services
provided to a recipient (global billing) as set out in the office's medical
policy;
(C) duplicate billing;
or
(D) claims for services or
materials determined to have been not medically reasonable or necessary;
or
(7) the overpayment
to the provider resulted from any other reason not specified in this
subsection.
(b) The
office shall determine the look-back period for audits as follows:
(1) For audits initiated on or before June
30, 2019, the audit look-back period shall be seven (7) years.
(2) For audits initiated on or after July 1,
2019, the audit look-back period shall be three (3) years and one hundred
eighty (180) days.
(3) The audit
look-back period accounts for and includes the timely filing period described
in 405 IAC 1-1-3 for determining the
available audit dates.
(4) The
look-back date begins on the date of audit initiation or when the office
discovers a credible allegation of fraud or abusive billing practices,
whichever is earliest.
(c) The office shall limit its audit to
claims submitted and paid by the office during the appropriate look-back
period. Once the office begins its audit, all claims within the audit look-back
period remain viable for audit and recoupment throughout the audit and appeal
process.
(d) If the office
discovers information that may indicate a credible allegation of fraud or
abusive billing practices, or a claims processing error rate greater than
thirty percent (30%), it may increase the audit look-back period from three (3)
years and one hundred eighty (180) days to seven (7) years.
(e) Underpayments discovered by the office in
the course of an audit shall be accounted for as follows:
(1) The sum of such underpayments shall
reduce the sum of overpayments identified in the audit.
(2) The provider, at its own expense, may
elect to examine the claims under audit for underpayments. If the provider
identifies underpayments, then the sum of those underpayments, if verified by
the office, shall reduce the sum of overpayments identified.
(3) Underpayments shall only reduce
overpayment findings.
(f) Under IC 12-15-21-3(5), the office may
determine the amount of overpayment made by a provider by means of a random
sample and extrapolation audit. The office shall conduct the random sample and
extrapolation audit in accordance with generally accepted statistical methods,
and shall base the selection criteria on a random sampling methodology
generally accepted by the statistical profession.
(g) In the event that the provider wishes to
appeal the accuracy of the random sampling methodology, the provider may
either:
(1) present evidence to show that the
sample used by the office was invalid and therefore cannot be used to project
the overpayments identified in the sample to total billings for the audit
period; or
(2) conduct an audit, at
the provider's expense, of either a valid random sample audit, using the same
random sampling methodology as used by the office, or an audit of one hundred
percent (100%) of medical records of payments received during the audit period.
Any such audit shall:
(A) be completed within
one hundred eighty (180) calendar days of the date of appeal; and
(B) demonstrate that the provider's records
for the unaudited services provided during the audit period were in compliance
with state and federal law. The provider must submit supporting documentation,
subject to review and approval by the office, to demonstrate this
compliance.
(h) If the office determines that an
overpayment has occurred, the office shall notify the provider by certified
mail. A provider who receives a notice may elect to do one (1) of the
following:
(1) Repay the amount of the
overpayment pursuant to IC 12-15-13-3.5(e) for a noninstitutional provider or
IC 12-15-13-4(e) for an institutional provider.
(2) Request a hearing and repay the amount of
the alleged overpayment pursuant to IC 12-15-13-3.5(e) for a noninstitutional
provider or IC 12-15-13-4(e) for an institutional provider.
(i) The office shall initiate
recoupment proceedings to collect any overpayment that is not repaid within
three hundred (300) calendar days after the provider's receipt of the final
calculation notice under section 11(d) or 12(e) of this rule as applicable. The
office may recoup an overpayment until it is satisfied through any of the
following methods:
(1) Offset the amount of
the overpayment against current Medicaid payments to a provider.
(2) In the case of an institutional provider,
offset the amount of the overpayment to any or all of the Medicaid facilities
owned by the provider.
(j) The office shall assess an interest
charge in addition to the amount of overpayment identified in the notice of
overpayment provided in subsection (d). Such interest charge shall not exceed
the percentage set out in IC 12-15-13-3.5(g) for a noninstitutional provider or
IC 12-15-13-4(h) for an institutional provider. Such interest charge shall be
applied to the total amount of the overpayment, less any subsequent repayments.
Under IC 12-15-21-3(6), the interest shall:
(1) accrue:
(A) from the date of the overpayment to the
provider; or
(B) for extrapolated
overpayments, from the last paid date of the audit period;
(2) apply to the net outstanding overpayment
during the periods in which such overpayment exists; and
(3) be assessed even if the provider repays
the overpayment to the office within thirty (30) days after receipt of the
notice of the overpayment.
(k) If the office recovers an overpayment to
a provider that is subsequently found not to have been owing to the office,
either in whole or in part, then the office shall pay to the provider interest
on the amount erroneously recovered from the provider. Such interest shall
accrue:
(1) from the date that the office
recovered the overpayment until the date the overpayment is restored to the
provider; and
(2) at the rate of
interest that shall not exceed the rate set out in IC 12-15-13-3.5(g) for a
noninstitutional provider or IC 12-15-13-4(h) for an institutional provider.
For hospitals that receive a notice that the provider has
been underpaid by the office as a result of the cost settlement process, the
office shall pay interest to the hospital on the amount of the underpayment
beginning on the date of the underpayment at the rate outlined in subsection
(e)(2).
(l)
Nothing in this section shall be construed to preclude the office from revising
a provider's rate of reimbursement under
405 IAC 1-12 or
405 IAC 1-14.6 as a result of an
audit.
