DAR File No. 39914

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-512

Use of Extrapolation in Provider Audits

Notice of Proposed Rule

(New Rule)

DAR File No.: 39914
Filed: 11/05/2015 09:34:38 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule is to comply with rulemaking requirements set forth in S.B. 61, passed during the 2015 General Session of the legislature.

Summary of the rule or change:

This new rule complies with rulemaking requirements set forth in S.B. 61 (2015). It sets forth the conditions under which the Department or one of its contractors may use extrapolation in provider audits.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this rule only sets forth conditions of extrapolation in provider audits. It neither affects current payment rates to Medicaid providers nor services to Medicaid recipients.

local governments:

There is no impact to local governments because this rule only sets forth conditions of extrapolation in provider audits. It neither affects current payment rates to Medicaid providers nor services to Medicaid recipients.

small businesses:

There is no impact to small businesses because this rule only sets forth conditions of extrapolation in provider audits. It neither affects current payment rates to Medicaid providers nor services to Medicaid recipients.

persons other than small businesses, businesses, or local governmental entities:

There is no impact because this rule only sets forth conditions of extrapolation in provider audits. It neither affects current payment rates to Medicaid providers nor services to Medicaid recipients.

Compliance costs for affected persons:

There is no impact because this rule only sets forth conditions of extrapolation in provider audits. It neither affects current payment rates to a single Medicaid provider nor services to a Medicaid recipient.

Comments by the department head on the fiscal impact the rule may have on businesses:

There is no fiscal impact on business because it does not change payment rates to Medicaid providers or the kind or amount of services that Medicaid pays for eligible Medicaid participants.

Joseph K. Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

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:

12/31/2015

This rule may become effective on:

01/07/2016

Authorized by:

Joseph Miner, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-512. Use of Extrapolation in Provider Audits.

R414-512-1. Introduction and Authority.

This rule implements rulemaking required by Section 26-18-20. It sets forth the conditions under which the Department or one of its contractors may use extrapolation as defined in Section 63A-13-102.

 

R414-512-2. Definition.

"Contractor" means a contractor or subcontractor of the Department.

 

R414-512-3. Use of Extrapolation Limited.

(1) The procedures set forth in Rule R380-400 may be used only if the Department or one of its contractors implements extrapolation pursuant to this rule.

(2) The Department or a contractor that conducts audits of providers on behalf of the Department shall:

(a) have on staff or contract with a medical or dental professional who is experienced in the treatment, billing, and coding procedures used by the type of provider being audited; and

(b) use the services of the appropriate professional described in Subsection R414-512-3(2)(a) if the provider who is the subject of the audit disputes the findings of the audit.

(3) The Department or a contractor may not base a finding of overpayment or underpayment on extrapolation as defined in Section 63A-13-102, unless:

(a) there is a determination that the level of payment error involving the provider exceeds a 10% error rate:

(i) for a sample of claims for a particular service code; and

(ii) over a three-year period of time;

(b) documented education intervention has failed to correct the level of payment error; and

(c) the value of the claims for the provider, in aggregate, exceeds $200,000 in reimbursement for a particular service code on an annual basis.

(4) If a contractor intends to implement the use of extrapolation as a method of auditing claims, the contractor shall, before adopting the extrapolation method of auditing:

(a) report its intent to use extrapolation to the Department; and

(b) proceed with the use of extrapolation only after the Department has granted permission.

(5) If the Department or a contractor determines Subsection R414-512-3(3)(a) through (c) is applicable to a provider, the Department or the contractor may use extrapolation only for the service code associated with the findings under that subsection.

(6) If extrapolation is used under this rule, a provider may appeal the results of the audit based on:

(a) each individual claim; or

(b) the extrapolation sample.

(7) Nothing in this rule limits a provider's right to appeal the audit under Title 63G, Chapter 4, the Medicaid program and its manual or rules, or other laws or rules that may provide remedies to providers.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: 2016

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3