Current through Register Vol. 24-18, September 15, 2024
(1)
Following the medicaid agency's evaluation of an entity's records including,
but not limited to, claims, encounter data, or payments, the agency may do any
combination of the following:
(a) Deny a claim
or claim line.
(b) Recover an
improperly paid claim.
(c) Instruct
the entity to submit:
(i) Additional
documentation; or
(ii) A new claim.
If the entity fails to submit a new claim within sixty calendar days, the
agency denies the new claim as untimely.
(d) Request a refund of an improper payment
to the agency by check.
(e) Refer
an overpayment to the office of financial recovery for collection.
(f) Issue a preliminary finding, which the
entity may dispute under WAC
182-502A-0801.
(i) If an entity agrees with the preliminary
finding before the deadline stated in the notice, the entity must notify the
agency in writing. The agency then issues a final notice.
(ii) If an entity does not respond by the
agency's deadline, the agency issues a final notice.
(g) Issue an overpayment notice or final
notice, which the entity may appeal under WAC
182-502A-0901.
(i) The final notice includes:
(A) The asserted overpayment or improper
payment amount;
(B) The reason for
an adverse determination;
(C) The
specific criteria and citation of legal authority used to make the adverse
determination;
(D) An explanation
of the entity's appeal rights;
(E)
The appropriate procedure to submit a claims adjustment, if applicable;
and
(F) One or more of the
following:
(I) Directives;
(II) Educational intervention; or
(III) A program integrity compliance
plan.
(ii) Upon
request, the agency allows an entity with an adverse determination the option
of repaying the amount owed according to a negotiated repayment plan of up to
twelve months. Interest may be calculated and charged on the remaining balance
each month.
(h) Recover
interest under
RCW
41.05A.220.
(i) Impose civil penalties under
RCW
74.09.210.
(j) Refer the entity to appropriate licensing
authorities for disciplinary action.
(k) Refer the entity to the agency's medical
dental advisory committee for review and potential termination of the contract
or core provider agreement.
(l)
Determine it has sufficient evidence to make a credible allegation of fraud.
The agency then:
(i) Refers the case to the
medicaid fraud control division and any other appropriate prosecuting authority
for further action; and
(ii)
Suspends some or all Washington apple health payments to the entity unless the
agency determines there is good cause not to suspend payments under
42 C.F.R.
455.23.
(2) The agency may assess an overpayment and
terminate the core provider agreement if an entity fails to retain adequate
documentation for services billed to the agency.
(3) At any time during a program integrity
activity, the agency may issue a final notice if the entity:
(a) Stops doing business with the
agency;
(b) Transfers control of
the business;
(c) Makes a
suspicious asset transfer;
(d)
Files for bankruptcy; or
(e) Fails
to comply with program integrity activities.
(4) The entity must repay any overpayment
identified by the agency within sixty calendar days of being notified of the
overpayment, except when a repayment plan is negotiated with the agency under
subsection (1)(g)(ii) of this section.
