This bill amends section 68-974 of the Revised Statutes Cumulative Supplement, 2024, to strengthen the integrity of the Medical Assistance program by establishing clearer guidelines for program integrity contractors and recovery audit contractors. Key provisions include requiring contractors to provide written justification before starting audits, limiting claims reviews to one year from the date of payment (down from four years), and allowing adjustments to payments only in cases of fraud after this period. The bill also mandates that contractors supply sufficient information in records requests, develop procedures for resubmitting claims adjustments, and utilize licensed health care professionals to establish relevant audit methodologies.

Additionally, the bill introduces new definitions related to fraud and overpayment, clarifying terms such as "allegations," "fraud," and "fraud hotline tip." It establishes a detailed notification process for adverse determinations, allows electronic submission of records by providers, and ensures that no overpayments are recovered until all appeals are exhausted unless credible fraud is present. The department is also required to compile and publish annual performance metrics related to recovery audit contractors and implement educational programs for providers to address common audit issues. Overall, these amendments aim to streamline the audit process, protect providers' rights, and enhance the efficiency of the Medical Assistance program while improving fraud detection and recovery efforts.

Statutes affected:
Introduced: 68-974