2011 Session

Budget Amendments - SB800 (Committee Approved)

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Home and Community-Based Services Audits (language only)

Item 297 #18s

Item 297 #18s

Health And Human Resources
Medical Assistance Services, Department of

Page 268, after line 55, insert:
"YYYY.  The Department of Medical Assistance Services shall develop a methodology for conducting utilization and review audits of home and community based waiver services in consultation with service providers no later than September 30, 2011.  The methodology shall consider inclusion of the following: 1) an audit shall extend for no longer than a continuous, six month period unless evidence of fraud or abuse requires additional time; 2) reviews shall involve a sampling of providers regardless of the size, number of claims, location, or amount of annual Medicaid revenue; 3) provider reviews shall be a random sample of no more than five percent of the  Medicaid records; 4) providers found in substantial compliance, defined as conforming with regulations at least 80 percent of the time, will not be subject to a retraction; 5) Medicaid records that document substantial compliance shall be considered compliant with regulation; 6) additional documentation from a supervisor that provides a plan of corrective action prior to the audit or provides legitimate reasons for the difference between the care plan and services provided shall be considered compliant and will not be subject to retractions for non-compliance with regulations; 7) retractions shall only be assessed when the provider is not in substantial compliance.  Any such retraction shall be only for the unit(s) which were deemed not in compliance.  If during the utilization and review audit there is found to be suspected fraud, abuse or neglect it shall be reported to the appropriate agency."

(This amendment requires the Department of Medical Assistance Services to develop a methodology for home and community based utilization and review audits in consultation with provider groups. Language requires the consideration of seven factors in the development of the methodology including length of reviews, parameters around samples taken, and what constitutes compliance. Budget language requires evidence of fraud and abuse are grounds for retraction and not clerical errors and that retractions shall only be assessed when the provider or medical record is not in substantial compliance with regulations and only for the unit(s) deemed not in compliance.)