La. Admin. Code tit. 50 § I-4117

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-4117 - Claims Review

A. BHSF establishes the following procedures for review of bills and claims submitted to it or its fiscal intermediary.

1. Prepayment Review

a. Upon concurrence of the director of BHSF and the director of Program Integrity, bills or claims submitted by a provider may be reviewed by BHSF, its contractor(s), or its fiscal intermediary prior to the issuing of or denial of payment or reimbursement.

b. If, during the prepayment review process, it is determined that the provider may be overpaid, BHSF, its contractor(s), or its fiscal intermediary must conduct an investigation to determine the reasons for and estimates of the amount of the potential overpayments.

i. If it is determined that evidence exists which would lead the director of BHSF and the director of Program Integrity to believe that the provider, provider-in-fact, agent of the provider, or affiliate of the provider has engaged in fraudulent, false, or fictitious billing practices or willful misrepresentation, current and future payments shall be withheld, suspended, or zero paid.

ii. If it is determined that evidence exists which would lead the director of BHSF and the director of Program Integrity to believe that overpayments may have occurred through reasons other than fraudulent, false or fictitious billing or willful misrepresentation, current and future payments may be withheld, suspended, or zero paid.

c. Prepayment review is not a sanction and cannot be appealed nor is it subject to an informal hearing. In the case of an ongoing criminal or outside governmental investigation, information related to the investigation shall not be disclosed to the provider, provider-in-fact or other person unless release of such information is otherwise authorized or required under law. Denials or refusals to pay individual bills or claims that are the result of the edit and audit system are not withholdings of payments.

d. Prepayment review is conducted at the absolute discretion of the director of BHSF and the director of Program Integrity.

2. Post-payment Review

a. Providers have a right to receive payment only for those bills that are valid claims. A person has no property interest in any payments or reimbursements from Medicaid, which are determined to be an overpayment or are subject to payment review. After payment to a provider, BHSF, its contractor(s), or its fiscal intermediary may review any or all payments made to a provider for the purpose of determining if the amounts paid were for valid claims.

b. If, during the post-payment review process, it is determined that the provider may have been overpaid, BHSF, its contractor(s), or its fiscal intermediary must conduct an investigation to determine the reasons for and estimated amounts of the alleged overpayments.

i. If it is determined that evidence exists that would lead the director of BHSF and the director of Program Integrity to believe that the provider, provider-in-fact, agent of the provider, or affiliate of the provider may have engaged in fraudulent, false, or fictitious billing practices or willful misrepresentation, current and future payments shall be withheld, suspended and/or zero paid.

ii. If it is determined that evidence exists that overpayments may have occurred through reasons other than fraud or willful misrepresentation, current and future payments may be withheld, suspended and/or zero paid.

c. Post-payment review resulting in a sanction(s) is appealable and subject to an informal hearing. In the case of an ongoing criminal or outside government investigation, information related to the investigation shall not be disclosed to the provider, provider-in-fact or other person. Denials or refusals to pay individual bills that are the result of the edit and audit system are not withholdings of payments.

d. Post-payment review is conducted is at the absolute discretion of the director of BHSF and director of Program Integrity.

La. Admin. Code tit. 50, § I-4117

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 25:1634 (September 1999), repromulgated LR 29:588 (April 2003), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38: 2777 (November 2012).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance Program Integrity Law).