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Health Law Advisory Bulletin
Washington’s New Medicaid Audit
Regulations: No More Mr. Nice Guy
By
Roger
L. Jansson and Robert
G. Homchick
[July 2007]
The Washington Health and Recovery Services Administration (HRSA)
has completely overhauled the Medicaid audit and appeals process.
HRSA issued the new rules governing audits which went into effect
June 1, 2007. (See http://apps.leg.wa.gov/WAC/default.aspx?cite=388-502A.)
In general, the new rules significantly restrict providers’
rights. For example, the new rules:
- Reduce advance notification for on-site audits from 20 working
days to 10 working days (with the exception of a 30-calendar-days
notice for hospitals).
- Allow HRSA to bypass the dispute conference and issue a final
audit report when certain conditions are met. For instance, HRSA
reserves the right to bypass the dispute conference if a provider
“fails to participate or comply with the department’s
audit process or unduly delays the department’s audit process.”
- Reference existing documentation requirements and “clarify”
that a provider’s bill for services, appointment books,
accounting records, or other similar documents alone may not constitute
appropriate documentation of services.
- Provide that billing adjustments to paid claims do not
affect the original audit universe, even if the provider properly
rebills claims for an adjustment.
- Require the interest on overpayments to be extrapolated, despite
the fact that the statutory basis for imposing interest does not
contemplate extrapolation of interest on overpayments and the
statistical validity of extrapolating interest is questionable.
- Assert HRSA’s authority to initiate unlimited reaudits
of the same audit period.
- Eliminate revised draft reports. HRSA previously issued such
reports to reflect any areas of agreement with providers prior
to the dispute conference.
- Authorize HRSA to issue subpoenas for records pursuant to RCW
43.20A.605, including depositions or testimony taken under oath.
- Remove protective language requiring HRSA to destroy records
at the end of the audit and to not remove original records from
the provider’s office. HRSA claims it will continue to follow
these practices but is unwilling to be bound by regulations.
- Confirm that HRSA does not reimburse administrative fees associated
with an audit, even if the provider prevails.
- Expand the scope of audits to include the clinical determinations
of whether the services were “medically necessary”
and “provided at the appropriate level of care.”
- Reduce the time period for the provider to dispute draft audit
findings from 45 days to 30.
- Require the provider to personally attend the dispute conference
in Olympia, regardless of the inconvenience, and regardless of
whether the provider has engaged counsel to handle the appeal.
- Require the provider to schedule the dispute conference within
60 days of the date the provider receives written acceptance of
the dispute, regardless of the complexity of the appeal or the
time required to prepare.
- Eliminate the ability to request an extension of the deadline
for requesting a dispute conference. Historically extensions were
freely granted.
The new regulations governing Medicaid audits contain a host of
traps for the unwary. Providers should exercise caution in responding
to audits and initiating the appeal process under these new rules.
Should you have any questions about the new rules or the audit process,
please feel free to contact Roger Jansson, Bob Homchick or your
usual Davis Wright Tremaine attorney.
For more information, please
contact:
This advisory is
a publication of the Health Law Group of Davis Wright Tremaine LLP.
Our purpose in publishing this
advisory is to inform our clients and friends of recent legal developments.
It is not intended, nor should it be used, as a substitute for specific
legal advice as legal counsel may only be given in response to inquiries
regarding particular situations. Attorney Advertising. Prior results
do not guarantee a similar outcome. Thank you.
Copyright 2007, Davis Wright Tremaine LLP.
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