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Title: Section 86-5.7 - Audits

86-5.7 Audits.

(a) All fiscal and statistical records and reports shall be subject to audit. In this respect, any rate of payment certified by the State Commissioner of Health based on the initial submission of base-year data and reports will be construed to represent a provisional rate until such audit is performed and completed, at which time such rate or adjusted rate will be construed to represent the final rate. In addition to verifying costs as reports, this audit will determine if the cost per visit or hour presented by the provider have, in fact, been those used in monthly chart billings.

(b) Subsequent to the filing of required fiscal and statistical reports, field audits shall be conducted of the records of LTHHCP in a time and manner to be determined by the department.

(c) The required fiscal and statistical reports shall be subject to audit for a period of six years from the date of their filing with the department. This limitation shall not apply to situations in which fraud may be involved.

(d) Upon completion of the audit, the LTHHCP shall be afforded a closing conference. The LTHHCP may appear in person or by anyone authorized in writing to act on behalf of the LTHHCP. The LTHHCP shall be afforded an opportunity at such conference to produce additional documentation in support of any modifications requested in the audit.

(e) The LTHHCP shall be provided with the final audit report, the rate computation sheet and any resulting revision of the rate of reimbursement, which shall be final unless, within 30 days of receipt of the final audit report, the long-term home health care program initiates a bureau review of such final audit report by notifying the Division of Health Care Financing, by registered or certified mail, detailing the specific items of the audit report with which the provider disagrees and such other material as the provider wishes to submit in its behalf, and forwarding all material documentation in support of the LTHHCP's position.

(f) The LTHHCP shall be notified in writing of the determination of the controverted items of the final audit report, including a statement of the reasons for such adjustments and the appropriate citation to applicable law, regulation or policy. The rate as adjusted in accordance with the determination of the bureau review shall be final, except that the LTHHCP may, within 30 days of receipt of the determination of the bureau review, initiate a hearing to refute those items of the audit report adverse to the interests of the LTHHCP presenting a factual issue by serving on the commissioner, by certified or registered mail, a notice containing a statement of the legal authority and jurisdiction under which the hearing should be held, a reference to the particular sections of the statutes and rules involved, and a statement of the controverted items of the audit report and bureau determination, together with copies of any documentation relied on by the LTHHCP in support of its position.

(1) Upon receipt of such notice, the commissioner shall:

(i) designate a hearing officer to hear and recommend;

(ii) establish a time and place for such hearing; and

(iii) notify the LTHHCP of the time and place of such hearing at least 15 days prior thereto. The issues and documentation presented by the LTHHCP at such hearing shall be limited to the factual issues and documentation presented at the bureau review.

(2) The final audit report shall be presumptive evidence of its content. The burden of proof at any such hearing shall be upon the LTHHCP to prove by substantial evidence that the items therein contained are incorrect.

(3) The hearing shall be conducted in conformity with section 12-a of the Public Health Law and the State Administrative Procedure Act.

(4) At the conclusion of the hearing, the LTHHCP may submit memoranda on any legal issues which it deems relevant to the proceeding. Such memoranda shall become part of the official record of hearing.

(g) Rate revisions resulting from the procedure set forth in this section shall be made retroactive to the period or periods during which the rates based on the periods audited were established.


VOLUME A-2 (Title 10)