Section 504.8 - Audit and claim review.

504.8 Audit and claim review. (a) Providers shall be subject to audit by the department and with respect to such audits will be required:

(1) to reimburse the department for overpayments discovered by audits in accordance with Parts 516 and 517 of this Title;

(2) to pay restitution for any direct or indirect monetary damage to the program resulting from their improperly or inappropriately furnishing services or arranging for, ordering, or prescribing care, services or supplies, in accordance with Parts 515 and 516 of this Title;

(3) to reimburse the auditing agency for the costs incurred by the department in performing the audit where records are not maintained in a readily reviewable form; and

(4) to pay any statutorily authorized fine or penalty.

(b) The department may conduct or have conducted audits and claims reviews which may be limited to reviews of costs of operation or which may involve reviews of the quality, appropriateness, and necessity of care provided and adherence to established department policy and procedures or conduct investigations as to the provider's conduct relative to unacceptable practices.

(c) The department, its fiscal agent, or the Department of Health upon prepayment review, may deny claims, adjust claims to eliminate noncompensable items or to reflect established rates or fees, correct obvious or mathematical errors, pend claims for further audit or review, or approve the claim for payment, subject to post-payment audit and verification.

(d) Where the department's routine utilization review procedures, an analysis of claims, or initial onsite audit findings indicate that a provider has claimed or is claiming for care, services or supplies which may be inconsistent with regulations governing the program or with established standards for quality of care, or which are inappropriate to the client's needs, not medically necessary or in excess of the client's medical needs, payment of all claims submitted and of all future claims may be delayed or suspended pending completion of an investigation. A notice of the withholding of payment shall be sent to the provider contemporaneous with withholding of payments.

 

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