Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule establishes a statistical methodology
where the billing forms or claims for payment submitted by Medicaid providers
may be examined to determine compliance with Title XIX (Medicaid) Program
requirements and proper payment, and this rule also sets forth the manner in
which providers may challenge the results.
(1) The following definitions will be used in
administering this rule:
(A) "Claim for
payment" or "claim" means the Internal Control Number (ICN) and the associated
data submitted to the Medicaid agency for the purpose of obtaining payment by
the Title XIX Medicaid Program;
(B)
"Disproportionate Stratified Random Sampling Technique" means a sampling method
in which the size of the sample drawn from a particular stratum is not
proportional to the relative size of that stratum;
(C) "Medicaid agency" or "the agency" means
the single state agency administering or supervising the administration of the
state Medicaid plan;
(D)
"Overpayment" means an amount of money paid to a provider by the Medicaid
agency to which the provider was not entitled by reason of improper billing,
error, fraud, abuse, lack of verification, or insufficient medical
necessity;
(E) "Provider" means any
person, partnership, corporation, not-for-profit corporation, professional
corporation, or other business entity that enters into a contract or provider
agreement with the Medicaid agency for the purpose of providing services to
Medicaid-eligible persons and obtaining from the Medicaid agency reimbursement
for services;
(F) "Sampling Unit"
means one (1) of the units into which an aggregate (e.g. total paid on claims)
is divided for the purpose of sampling. For example a sampling unit may be
ICNs, a specific procedure code or codes, or participant DCNs (Document Control
Numbers);
(G) "Stratum" refers to a
sampling method in which the universe is divided into non-overlapping
subgroups. Each of the subgroups is called a stratum, and two (2) or more
subgroups are called strata; and
(H) "Universe" means all claims for payment
or all claims relating to a specific service or a specific item or merchandise
submitted by a provider between two (2) certain dates.
(2) The Medicaid agency may use a
Disproportionate Stratified Random Sampling Technique to establish provider
overpayments. This technique is an extrapolation of a statistical sampling of
claims used to determine the total overpayment for recoupment.
(3) When a total overpayment has been
computed by statistical sampling, the Medicaid agency may proceed to recover
the full amount of the overpayment from the provider as an amount due. Recovery
of the overpayment shall be accomplished according to the provisions of
13 CSR
70-3.030(6), except that in cases
where the amount due was computed by statistical sampling, the notice informing
the provider of the amount due required by
13 CSR
70-3.030(6)(A) and (B) shall also
contain the following information:
(A) The
dates of service and total paid for the Universe;
(B) Definition of the sampling
unit;
(C) The number of claims in
the statistical sample; and
(D) A
generally summarized description of the reasons for the overpayment
determinations with all claims in the statistical sample identified as to which
overpayment description applies to each.
(4) The extrapolated overpayment is a final
decision regarding administration of the state Medicaid plan and is subject to
appeal in accordance with section
208.156,
RSMo.
