This bill amends section 68-974 of the Revised Statutes Cumulative Supplement, 2024, to enhance the integrity of the Medical Assistance Program by establishing new requirements for program integrity contractors and recovery audit contractors. Key changes include the requirement for contractors to provide clear written justification before commencing an audit, limiting claims reviews to one year from the date of payment (down from four years), and ensuring that sufficient information is provided for providers to identify relevant records. The bill also mandates the development of procedures for resubmitting claims adjustments, the use of licensed healthcare professionals in audit methodologies, and introduces specific timelines for audit notifications and appeals to ensure providers have adequate time to respond.

Additionally, the bill outlines that no payment shall be recovered for services that were authorized or if the recovery process is initiated more than one year after payment. It prohibits extrapolated overpayments without evidence of a sustained error pattern and requires that all recovered amounts be returned to the medical assistance program. The bill emphasizes educational programs for providers and mandates annual reporting to the Legislature on the status of contracts and recovery efforts. It also introduces new definitions related to fraud and program integrity, clarifying the roles of various entities involved in the auditing process, while making several deletions to existing legal language to reflect these updates.

Statutes affected:
Introduced: 68-974