This bill amends section 68-974 of the Revised Statutes Cumulative Supplement, 2024, to improve the integrity of the Medical Assistance Program in Nebraska 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 claim reviews to one year from the payment date (with exceptions for fraud), and ensuring that records requests are relevant and proportional to the services being audited. The bill also mandates the development of procedures for resubmitting claims adjustments and the use of licensed healthcare professionals to establish audit methodologies. Additionally, it introduces an appeals process for providers, ensuring that no overpayment is recouped until all appeals are exhausted unless credible evidence of fraud exists.

Furthermore, the bill introduces new definitions related to fraud and overpayment, clarifying terms such as "allegations," "fraud," and "fraud hotline tip." It removes previous definitions that were less precise or redundant, streamlining the language to enhance clarity and align with current practices in fraud detection and prevention. The bill aims to create a more transparent and fair auditing process within the Medical Assistance Program, including the prohibition of extrapolated overpayments without evidence of a sustained error pattern and allowing providers to submit records electronically. Overall, these amendments seek to strengthen the integrity of the medical assistance system in Nebraska.

Statutes affected:
Introduced: 68-974