Title: Section 519.18 - Hearing procedure.

519.18 Hearing procedure. (a) The issues and documentation considered at the hearing are limited to issues directly relating to the final determination. An appellant may not raise issues regarding the methodology used to determine any rate of payment or fee, nor raise any new matter not considered by the department upon submission of objections to a draft audit or notice of proposed agency action.

(b) Technical rules of evidence followed in a court of law will not be followed, but evidence must be relevant and material.

(c) Irrelevant and unduly repetitious testimony and cross-examination will be excluded.

(d) The appellant has the burden of:

(1) showing that the determination of the department was incorrect and that all claims submitted and denied were due and payable under the program, or that all costs claimed were allowable; and

(2) proving any mitigating factors affecting the severity of any sanction imposed.

Where the determination is based upon an alleged failure of the provider to comply with generally accepted business, accounting, professional or medical practices or standards of health care, the department must establish the existence of such practice or standard.

(e) Copies of records and documents in the possession of the department may be admitted into evidence as photocopies, however, the originals of such records and documents must be made available for inspection at the direction of the hearing officer whether in possession of the department or the appellant.

(f) Computer-generated documents prepared by the department or its fiscal agent to show the nature and amount of payments made under the program will be presumed, in the absence of direct evidence to the contrary, to constitute an accurate itemization of the payments made to a provider.

(g) An extrapolation based upon an audit utilizing a statistical sampling method certified as valid will be presumed, in the absence of expert testimony and evidence to the contrary, to be an accurate determination of the total overpayments made or penalty to be imposed. The appellant may submit expert testimony challenging the extrapolation by the department or an actual accounting of all claims paid in rebuttal to the department's proof.

(h) The decision after hearing must be supported by substantial evidence.

 

Volume

VOLUME C (Title 18)

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