(1)
Definitions.
"Authorized representative, " within the
context of this rule, means the person appointed to carry out audit or review
procedures, including assigned auditors, reviewers or agents contracted for
specific audits, reviews, or audit or review procedures.
"Claim " means each record received by the
department or the Iowa Medicaid enterprise that states the amount of requested
payment and the service rendered by a specific and particular Medicaid provider
to an eligible member.
"Clinical record" means a legible electronic
or hard-copy history that documents the criteria established for medical
records as set forth in rule
441-79.3 (249A). A claim form or billing statement does not constitute a clinical
record.
"Confidence level" means the statistical
reliability of the sampling parameters used to estimate the proportion of
payment errors (overpayment and underpayment) in the universe under
review.
"Customary and prevailing fee " means a fee
that is both (1) the most consistent charge by a Medicaid provider for a given
service and (2) within the range of usual charges for a given service billed by
most providers with similar training and experience in the state of
Iowa.
"Extrapolation " means that the total amount
of overpayment or underpayment will be determined by using sample data meeting
the confidence level requirement.
"Fiscal record" means a legible electronic
or hard-copy history that documents the criteria established for fiscal records
as set forth in rule
441-79.3 (249A). A claim form or billing statement does not constitute a fiscal
record.
"Overpayment" means any payment or portion
of a payment made to a provider that is incorrect according to the laws and
rules applicable to the Medicaid program and that results in a payment greater
than that to which the provider is entitled.
"Procedure code " means the identifier that
describes medical or remedial services performed or the supplies, drugs, or
equipment provided.
"Random sample " means a statistically valid
random sample for which the probability of selection for every item in the
universe is known.
"Underpayment" means any payment or portion
of a payment not made to a provider for services delivered to eligible members
according to the laws and rules applicable to the Medicaid program and to which
the provider is entitled.
"Universe " means all items or claims under
review or audit during the period specified by the audit or review.
(2)
Audit or review of clinical and
fiscal records by the department. Any Medicaid provider may be audited
or reviewed at any time at the discretion of the department.
a. Authorized representatives of the
department shall have the right, upon proper identification, to audit or review
the clinical and fiscal records to determine whether:
(1) The department has correctly paid claims
for goods or services.
(2) The
provider has furnished the services to Medicaid members.
(3) The provider has retained clinical and
fiscal records that substantiate claims submitted for payment.
(4) The goods or services provided were in
accordance with Iowa Medicaid policy.
b. Requests for provider records by the Iowa
Medicaid enterprise program integrity unit shall include Form 470-4479,
Documentation Checklist, which is available at
www.ime.state.ia.us/Providers/Forms.html, listing the specific records that must be provided for the audit or review
pursuant to paragraph 79.3(2) "J" to document the basis for services or
activities provided.
c. Records
generated and maintained by the department may be used by auditors or reviewers
and in all proceedings of the department.
(3)
Audit or review
procedures. The department will select the method of conducting an
audit or review and will protect the confidential nature of the records being
audited or reviewed. The provider may be required to furnish records to the
department. Unless the department specifies otherwise, the provider may select
the method of delivering any requested records to the department.
a. Upon a written request for records, the
provider must submit all responsive records to the department or its authorized
agent within 30 calendar days of the mailing date of the request, except as
provided in paragraph"b. "
b. Extension of time limit for submission.
(1) The department may grant an extension to
the required submission date of up to 15 calendar days upon written request
from the provider or the provider's designee. The request must:
1. Establish good cause for the delay in
submitting the records; and
2. Be
received by the department before the date the records are due to be
submitted.
(2) For
purposes of these rules, "good cause" has the same meaning as in Iowa Rule of
Civil Procedure 1.977.
(3) The
department may grant a request for an extension of the time limit for
submitting records at its discretion. The department shall issue a written
notice of its decision.
(4) The
provider may appeal the department's denial of a request to extend the time
limit for submission of requested records according to the procedures in
441-Chapter 7.
c. The
department may elect to conduct announced or unannounced on-site reviews or
audits. Records must be provided upon request and before the end of the on-site
review or audit.
(1) For an announced on-site
review or audit, the department's employee or authorized agent may give as
little as one day's advance notice of the review or audit and the records and
supporting documentation to be reviewed.
(2) Notice is not required for unannounced
on-site reviews and audits.
(3) In
an on-site review or audit, the conclusion of that review or audit shall be
considered the end of the period within which to produce records.
d. Audit or review procedures may
include, but are not limited to, the following:
(1) Comparing clinical and fiscal records
with each claim.
(2) Interviewing
members who received goods or services and employees of providers.
(3) Examining third-party payment
records.
(4) Comparing Medicaid
charges with private-patient charges to determine that the charge to Medicaid
is not more than the customary and prevailing fee.
(5) Examining all documents related to the
services for which Medicaid was billed.
e. Use of statistical sampling techniques.
The department's procedures for auditing or reviewing Medicaid providers may
include the use of random sampling and extrapolation.
(1) A statistically valid random sample will
be selected from the universe of records to be audited or reviewed. The sample
size shall be selected using accepted sample size estimation methods. The
confidence level of the sample size calculation shall not be less than 95
percent.
(2) Following the sample
audit or review, the statistical margin of error of the sample will be
computed, and a confidence interval will be determined. The estimated error
rate will be extrapolated to the universe from which the sample was drawn
within the computed margin of error of the sampling process.
(3) Commonly accepted statistical analysis
programs may be used to estimate the sample size and calculate the confidence
interval, consistent with the sampling parameters.
(4) The audit or review findings generated
through statistical sampling procedures shall constitute prima facie evidence
in all department proceedings regarding the number and amount of overpayments
or underpayments received by the provider.
f. Self-audit. The department may require a
provider to conduct a self-audit and report the results of the self-audit to
the department.
(4)
Preliminary report of audit or review findings. If the
department concludes from an audit or review that an overpayment has occurred,
the department will issue a preliminary finding of a tentative overpayment and
inform the provider of the opportunity to request a reevaluation.
(5)
Disagreement with audit or review
findings. If a provider disagrees with the preliminary finding of a
tentative overpayment, the provider may request a reevaluation by the
department and may present clarifying information and supplemental
documentation.
a.
Reevaluation
request. A request for reevaluation must be submitted in writing
within 15 calendar days of the date of the notice of the preliminary finding of
a tentative overpayment. The request must specify the issues of disagreement.
(1) If the audit or review is being performed
by the Iowa Medicaid enterprise surveillance and utilization review services
unit, the request should be addressed to: IME SURS Unit, P.O. Box 36390, Des
Moines, Iowa 50315.
(2) If the
audit or review is being performed by any other departmental entity, the
request should be addressed to: Iowa Department of Human Services, Attention:
Fiscal Management Division, Hoover State Office Building, 1305 E. Walnut
Street, Des Moines, Iowa 50319-0114.
b.
Additional information. A
provider that has made a reevaluation request pursuant to
paragraph"a" of this subrule may submit clarifying information
or supplemental documentation that was not previously provided. This
information must be received at the applicable address within 30 calendar days
of the mailing of the preliminary finding of a tentative overpayment to the
provider, except as provided in paragraph"c" of this
subrule.
c.
Disagreement
with sampling results. When the department's audit or review findings
have been generated through sampling and extrapolation and the provider
disagrees with the findings, the burden of proof of compliance rests with the
provider. The provider may present evidence to show that the sample was
invalid. The evidence may include a 100 percent audit or review of the universe
of provider records used by the department in the drawing of the department's
sample. Any such audit or review must:
(1) Be
arranged and paid for by the provider.
(2) Be conducted by an individual or
organization with expertise in coding, medical services, and Iowa Medicaid
policy if the issues relate to clinical records.
(3) Be conducted by a certified public
accountant if the issues relate to fiscal records.
(4) Demonstrate that bills and records that
were not audited or reviewed in the department's sample are in compliance with
program regulations.
(5) Be
submitted to the department with all supporting documentation within 60
calendar days of the mailing of the preliminary finding of a tentative
overpayment to the provider.
(6)
Finding and order for
repayment. Upon completion of a requested reevaluation or upon
expiration of the time to request reevaluation, the department shall issue a
finding and order for repayment of any overpayment and may immediately begin
withholding payments on other claims to recover any overpayment.
(7)
Appeal by provider of care.
A provider may appeal the finding and order of repayment and
withholding of payments pursuant to 441-Chapter 7. However, an appeal shall not
stay the withholding of payments or other action to collect the overpayment.
Records not provided to the department during the review process set forth in
subrule 79.4(3) or 79.4(5) shall not be admissible in any subsequent contested
case proceeding arising out of a finding and order for repayment of any
overpayment identified under subrule 79.4(6). This provision does not preclude
providers that have provided records to the department during the review
process set forth in subrule 79.4(3) or 79.4(5) from presenting clarifying
information or supplemental documentation in the appeals process in order to
defend against any overpayment identified under subrule 79.4(6). This provision
is intended to minimize potential duplication of effort and delay in the audit
or review process, minimize unnecessary appeals, and otherwise forestall fraud,
waste, and abuse in the Iowa Medicaid program. This rule is intended to
implement Iowa Code section
249A.4.
