MAD can seek recovery of overpayments through the recoupment
or repayment process. Overpayments are amounts paid to a MAD provider or other
entity in excess of the MAD allowable amount. Overpayment amounts must be
collected within 24 months of the initiation of recovery. Overpayment includes,
but is not limited to, payment for any claim for which the provider or other
entity was not entitled to payment because an applicable MAD NMAC rule and its
requirements were not followed. Payment made to a pharmacy for a controlled
substance or another prescribed drug item for which the prescriber did not
follow all state and federal regulations, laws or rules may be subject to
recoupment from the prescriber or entity to which the prescriber is associated.
Recovery of overpayments through a HSD contracted MCO is also subject to the
provisions of 8.308.22 NMAC.
A.
Auditing procedures:
(1) Prima
facie evidence: The audit findings generated through the audit procedure shall
constitute prima facie evidence in all MAD proceedings of the number and amount
of requests for payment as submitted by the provider or other entity.
(2) Use of statistical sampling techniques:
MAD's procedures for auditing a provider or other entity may include the use of
random sampling and extrapolation. When this procedure is used, all sampling
will be performed using generally accepted statistical methods and will yield
statistically significant results at a confidence level of at least 90 percent.
Findings of the sample will be extrapolated to the universe for the audit
period.
(3) Burden of proof: When
MAD's final audit findings have been generated through the use of sampling and
extrapolation, and the provider or other entity disagrees with the findings
based on the sampling and extrapolation methodology that was used, the burden
of proof of compliance rests with the provider or other entity. The provider or
other entity may present evidence to show that the sample was invalid. The
evidence must include a 100 percent audit of the universe of provider records
used by MAD in the drawing of its sample. Any such audit must:
(a) be arranged and paid for by the provider
or other entity;
(b) be conducted
by a certified public accountant;
(c) demonstrate that a statistically
significantly higher number of claims and records not reviewed in MAD sample
were in compliance with MAD NMAC rules, and
(d) be submitted to MAD with all supporting
documentation.
B.
Repayment process: A provider
or other entity can repay all or part of an overpayment with a lump sum payment
or a series of payments based on a schedule developed and mutually agreed to by
MAD and the provider or other entity. If a provider or other entity fails to
comply with the schedule, HSD will recover the overpayment and interest or
initiate other collection efforts.
C.
Recoupment process: Upon
written notice, MAD may withhold all or a portion of a provider or other
entity's payment on pending and subsequently received claims in order to
recover an overpayment, or it may suspend payment on all pending or
subsequently submitted claims, pending a final determination of the amount of
overpayment. All amounts must be recouped within 24 months. Recoupments may be
applied to other providers owned by the same entity when necessary to recoup
overpayments timely.
D.
Combination of processes: MAD can use both recoupment and
repayment process to collect an overpayment if:
(1) the provider is unlikely to remain a MAD
provider long enough for full recovery using recoupment alone;
(2) the provider is not enrolled through a
MAD PPA or contract; or
(3) the
average monthly payment to a provider or other entity is so low that recoupment
within 12 months is not feasible.
E.
Prepayment review: MAD may
require pre-payment review of claims submitted during a recoupment or repayment
process to ensure that subsequent claims are not inflated to compensate for
amounts recovered during the recoupment or repayment process. Prepayment review
may also be conducted as part of MAD's administrative
responsibilities.
