The Iron Triangle Part Two
The Iron Triangle Part Two
The Iron Triangle Part Two
So, for example, billing errors are found in a survey of a relatively small number of records. The assumption is that those errors will be found in all of the records. What might have been a small payback now becomes a tremendous payback.
So what regress is available to the provider agency? The private provider agency can approach the legislature and ask that the powers of the governmental agency be curtailed. The legislature has the capability of writing a bill that has the potential for "leveling the playing field."
Recently, that is what has happened.
In response to requests from some private provider agencies in New York, the NY State legislature has introduced legislature that, if passed, will go a long way towards curtailing the practices that have the provider agencies so upset. Senate bill 7821, introduced by Senator C. Johnson states "the legislature recognizes the need to balance the ability of the state to ensure the integrity of the medical assistance program with the need to afford due process to providers who are audited or subject to other actions to ensure that such actions are conducted in a fair and consistent manner.
The legislature also recognizes the need for established statutory standards regarding the conduct of audits and recovery of overpayments and other actions."
Following is a summary of the important features in the bill. Notice that the bill mandates the provision of guidelines for the use of extrapolation.
Summary of Specific Provisions:
Nothing in this legislation applies to fraud cases or recoveries based on findings of fraud.
There shall be no recoveries until 60 days after the issuance of the final report.
The recovery of overpayment shall not exceed 10% of the claim payable.
Protects providers from double jeopardy-multiple audits by more than one agency for the same
period of time.
Audits must follow policies that were in effect during the time period being audited.
Strengthens pre-audit and post- audit conference guidelines.
No recoveries shall be made based on the actions of another provider or agency.
Providers will be afforded 60 days to fix technical problems.
Provides guidelines for the use of extrapolation.
Underpayments shall be used to offset overpayments.
Any funds improperly withheld shall be returned with interest.
Audit staff must be properly trained.
OMIG must specify in writing which books, papers, records it has determined are necessary for
an audit and it must allow a reasonable amount of time for the provider to comply.
Fair procedures, practices and standards for recipients.
Whether or not the legislation is passed, or tabled, I cannot predict. To me, it appears to be a fair bill. It specifically states that nothing in the bill applies to fraud cases. Some quarters have attacked the bill based on their mistaken belief that it applies to fraud cases, which is clearly not so.
It will be interesting to follow the path of the bill.
What do you think?
Dr. Ira Jacobs has been in the field of developmental disabilities for over fifty years. He has covered a wide array of positions ranging from physical therapist to CEO of a large multi services treatment center. He has a strong interest in all matters affecting the developmental disabilities field
For more information visit his websitehttp://developmentaldisabilitiesissues.com.
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