OLR Bill Analysis

sHB 5257

AN ACT CONCERNING MEDICAID PROVIDER AUDITS.

SUMMARY:

By law, the Department of Social Services (DSS) commissioner must (1) produce a preliminary written report concerning any audit of a long term care facility and (2) provide the report to the audited facility within 60 days of the audit's conclusion.

This bill requires the commissioner to include in the report a clear and objective rationale for cost disallowances or findings that costs were not reasonable. He must (1) cite the specific statute or regulation under which the disallowances or findings were determined, (2) only apply statutes or regulations specific to the type of program or facility being audited, and (3) apply Medicare audit rules if there are no applicable state regulations. (It appears that the commissioner must apply the Medicare audit rules if there are applicable state statutes without corresponding regulations.)

The bill prohibits the commissioner from disallowing any costs without citing applicable statutes, regulations, or Medicare audit rules and providing a clear, written explanation of their objective application.

The bill also requires the DSS commissioner, by July 1, 2017, to report to the Human Services Committee on:

1. the percentage of providers subject to extrapolation in Medicaid audits (i.e., projecting the total value of submitted claims based on a sample of the claims) during FY 16,

2. the amount of overpayments discovered in such audits, and

3. any increases or reductions in the use of extrapolation and overpayment discoveries in FY 16 compared to FY 15.

EFFECTIVE DATE: July 1, 2016

COMMITTEE ACTION

Human Services Committee

Joint Favorable Substitute

Yea

17

Nay

0

(03/17/2016)