Human Services Committee
AN ACT CONCERNING MEDICAID PROVIDER AUDITS AND ELECTRONIC VISIT VERIFICATION
SUMMARY: This act places limits on medical assistance (e.g., Medicaid) provider audits by (1) prohibiting the Department of Social Services (DSS) from applying agency policies or other criteria to audits of claims submitted before the policies or other criteria were distributed to providers and (2) temporarily prohibiting DSS from extrapolating overpayments related to electronic visit verification (EVV).
The act also requires the DSS commissioner to report to the Human Services Committee on the implementation of the state-required EVV system by July 1, 2018. The report must include (1) any problems with system implementation, (2) recommendations to resolve identified problems, and (3) cost savings identified due to the EVV system.
EFFECTIVE DATE: July 1, 2017, except EVV provisions are effective upon passage.
DISTRIBUTION OF DSS POLICIES
The act prohibits the DSS commissioner from applying an agency policy, guideline, bulletin, manual provision, or other criteria when making determinations in a medical assistance provider audit unless it was promulgated and distributed, with its effective date, to a provider before the provider performed the service included in the audited claim.
TEMPORARY EVV-RELATED AUDIT RESTRICTION
The act temporarily prohibits the DSS commissioner from extrapolating overpayments caused by errors related to implementing a state-required EVV system, which, under the act, is a system also required by federal law that verifies the date, time, and site of a provider visit and services offered to a client in a Medicaid-funded and DSS-administered home or community-based service program. Generally, extrapolation means projecting the total value of submitted claims based on a sample of the claims.
The act prohibits DSS from extrapolating overpayments due to errors related to EVV by (1) non-medical providers from January 1, 2017 to May 1, 2017 and (2) medical home health care providers from April 1, 2017 to August 1, 2017.
Under the act, non-medical providers are Medicaid-enrolled home care providers who are not licensed by the Department of Public Health (DPH). Medical home health care providers are Medicaid-enrolled, DPH-licensed providers with Medicare certification to provide medically skilled home health care services under a registered nurse's supervision.