2012 Session

Budget Amendments - SB30 (Member Request)

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Chief Patron: Howell
Revise Home and Community Based Services Audits (language only)

Item 307 #27s

Item 307 #27s

Health And Human Resources
Medical Assistance Services, Department of

Page 239, after line 5, insert:
"LLL.  The Department of Medical Assistance Services shall implement a methodology for home- and community-based utilization and review audits that shall include:  (i) a review of no more than a twelve continuous month period unless evidence of fraud or abuse warrants an expanded audit period which shall then be documented for cause; (ii) a sampling of providers to be audited that assures a fair review of providers regardless of the size, number of claims, location, or amount of annual Medicaid revenue; (iii) a random selection methodology to choose a sufficient number of individual Medicaid records for audit that is statistically valid and reliable and would represent the overall practice of the service provider in billing for services; and; (iv) a methodology for calculating the assessment of payment retractions for errors in service billing that is based upon a "unit of service" rather than a claim that may likely include more than one unit of service.    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.  As directed by this Act, representatives  of providers of home- and community-based care services shall participate in the development of methodologies.  By October 1, 2013 a final report shall be made that includes an assessment of improvements achieved in the effectiveness and fairness of the audit methodologies applied to the home- and community based care services, as evidenced by reductions in audit finding appeals, audit findings challenged in circuit court, and court findings that reduced or eliminated the subject retraction of payments."

(This amendment requires the Department of Medical Assistance Services to revise the current methodology for home- and community-based services following the study required in Chapter 890 of the 2011 Acts of Assembly, Item 297, paragraph AAAA; and to report on the results of the revisions in causing improvement in audit findings.)