Current through Register Vol. 24-18, September 15, 2024
This section applies to entities that contract with the
medicaid agency to provide services in exchange for a capitated rate.
(1) Managed care organizations (MCOs) must
comply with and enforce all applicable program integrity:
(a) Federal and state laws and
regulations;
(b) Terms of their
contracts with the agency; and
(c)
Terms of their contracts with subcontractors and providers.
(2) MCOs must:
(a) Adopt and enforce program integrity
policies and procedures that guide the contractor's officers, employees,
agents, and subcontractors;
(b)
Include and enforce federal and state program integrity requirements in their
subcontracts and in their provider application, credentialing, and
recredentialing processes;
(c)
Adopt and implement methods for detecting and preventing fraud, waste, and
abuse to ensure payments to subcontractors and providers are proper and comply
with medic-aid regulations and billing instructions;
(d) Perform ongoing analyses of their
authorization, utilization, claims, providers' billing patterns, and encounter
data to detect improper payments;
(e) Conduct reviews, audits, and
investigations of subcontractors and providers;
(f) Report to the agency any:
(i) Fraud, waste, or abuse; and
(ii) Overpayments and recoveries.
(g) Recover overpayments to any
subcontractor or provider; and
(h)
Refer any suspected or potential fraud to the agency and to the medicaid fraud
control division or other law enforcement agency.
(3) MCOs must establish an appeals process,
similar to the dispute resolution process in WAC 182-502A-801, for their
subcontractors or providers to contest an assessment of an overpayment by a
managed care entity.
(4) MCOs'
subcontractors or providers do not have a right to an administrative hearing
under chapter 34.05 RCW or chapter 182-526 WAC to contest the results of the
appeals process. The MCO will provide notice and will state in the notice that
there is no right to an administrative hearing.
(5) Overpayment assessments by an MCO to its
subcontractor or provider that are not appealed or that are upheld after appeal
must be recovered from its subcontractors or providers within:
(a) Sixty calendar days of the overpayment
being identified and assessed against the subcontractor or provider;
or
(b) Sixty calendar days of
completion of an appeals process for the subcontractor or provider who disputes
the overpayment assessment.
(6) An MCO must report to the agency:
(a) Identification of an overpayment assessed
against a subcontractor or provider.
(b) Notification of a subcontractor's or
provider's appeal of an overpayment assessment.
(c) Results of an appeal of an overpayment
assessment from the subcontractor or provider.
(d) Recovery of the identified overpayment
assessed or settlement information as a result of the appeal.
(7) The agency may sanction an MCO
or assess liquidated damages when:
(a) The
agency identifies fraud, waste, or abuse by an MCO provider;
(b) The MCO fails to report MCO provider
overpayments; or
(c) Other
situations arise as identified in the contract.
