File No. 35216
This rule was published in the September 15, 2011, issue (Vol. 2011, No. 18) of the Utah State Bulletin.
Use of Statistical Sampling and Extrapolation
Notice of Proposed Rule
DAR File No.: 35216
Filed: 09/01/2011 03:21:53 PM
Purpose of the rule or reason for the change:
In their report to the Legislature, Number 2009-12, and in subsequent reports, the Office of Legislative Auditor General recommended that the State Medicaid program obtain authority to use statistical sampling to establish overpayment recoveries due the state. This rule sets forth the methodology to adopt that sampling methodology and sets standards for its use.
Summary of the rule or change:
The Department proposed an extrapolation rule that was published in February and never made effective. A committee of interested providers, the Department, and the Office of Inspector General of the Medicaid Program have met since that time and this rule is the result of that collaboration. All agree that the rule is much improved. The definitions have greater clarity, as well as the methodology. Extrapolation may only be applied for a maximum period of 36 months and the initial sample must be random. Statistical sampling techniques are authorized when: 1) a pattern of errors are discovered during an audit such that a transaction error rate greater than 10% is discovered or a dollar error rate of 5%; 2) sampling size must establish a confidence level of 95% and a confidence interval of plus or minus 5%; and 3) the estimated error rate will then be extrapolated to the universe from which the sample is drawn to establish the overpayment. All sampling will be based on a single provider and a single billing code. Detailed provider notification requirements are set forth in Section R380-400-7 of the rule. Section R380-400-8 of the rule sets forth the claims using the rule's statistical methodology which is based on sound scientific statistical principles is sufficient to satisfy the burden of establishing a claim for recovery, unless rebutted by sound statistical evidence by the provider.
State statutory or constitutional authorization for this rule:
- Section 26-18-3
- Section 26-1-5
Anticipated cost or savings to:
the state budget:
Savings are anticipated to the state budget, but the exact amount cannot be predicted.
Local governments provide Medicaid services and may be subject to recoveries under this rule.
Yes, small business provide Medicaid services and may be subject to recoveries under this rule.
persons other than small businesses, businesses, or local governmental entities:
Yes, businesses provide Medicaid services and may be subject to recoveries under this rule.
Compliance costs for affected persons:
Yes, there may be significant costs to Medicaid providers to respond to audits and recoveries performed as a result of this rule.
Comments by the department head on the fiscal impact the rule may have on businesses:
Businesses may have significant costs if audits find they received inappropriate payments, but there would be no fiscal costs to businesses as a result of the rule itself. This rule was developed with the participation of representatives from medical providers who would be affected by the rule in a negotiated rulemaking process. Although medical providers are not in agreement that extrapolation is the best way to determine the amount of recoveries they are agreed on the procedures for using statistical sampling and extrapolation when it would be applied as defined in this rule. The Department appreciate the support of these providers in the negotiated rulemaking process and for their helpful suggestions in improving the rule.
David Patton, PhD, Executive Director
The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:Health
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231
Direct questions regarding this rule to:
- Doug Springmeyer at the above address, by phone at 801-538-6971, by FAX at 801-538-6306, or by Internet E-mail at firstname.lastname@example.org
Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:
This rule may become effective on:
David Patton, Executive Director
R380. Health, Administration.
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2011/b20110915.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
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For questions regarding the content or application of this rule, please contact Doug Springmeyer at the above address, by phone at 801-538-6971, by FAX at 801-538-6306, or by Internet E-mail at email@example.com.