Title: Section 43-2.16 - Audits and recovery of overpayments

43-2.16 Audits and recovery of overpayments.

(a) Recovery of overpayments shall be made only upon a determination by the commissioner, his agents or designees, that such overpayments have been made, and recovery shall be made of all money paid to the provider to which it has no lawful right or entitlement.

(b) Recovery of overpayments pursuant to this subject shall not preclude the commissioner or any other authorized governmental body or agency from taking any other action with respect to the provider, including auditing or reviewing other payments or claims for payment for the same or similar periods, imposing program sanctions, or taking any other action authorized by law.

(c) The commissioner may utilize any lawful means to recover overpayments, including civil lawsuit, participation in a proceeding in bankruptcy, common law set-off, or such other actions or proceedings authorized or recognized by law.

(d) All fiscal and statistical records and reports of providers and prescriptions filled or refilled which are used for the purpose of establishing the provider's right to payment under the program, and any underlying books, records and documentation which formed the basis for such fiscal and statistical records and reports, shall be subject to audit. All underlying books, records and documentation, including all prescriptions filled or refilled, shall be kept and maintained by the provider for a period of not less than three years from the date of completion of such reports, or the date upon which the fiscal and statistical records were required to be filed, whichever is later, or the date the prescription was filled or refilled.

(e) All claims made under the program shall be subject to audit by the commissioner, his agents or designees, for a period of six years from the date of their filing, or as required by state law, regulation or funding source. This limitation shall not apply to situations in which fraud may be involved or where the provider or an agent thereof prevents or obstructs the performance of an audit pursuant to this Part.