On June 1, 2018, Connecticut Governor Dannel P. Malloy signed into law Public Act No. 18-76 “An Act Concerning Audits of Medical Assistance Providers” (PA 18-76), which makes several changes to the Medicaid provider audit process conducted by or on behalf of the Connecticut Department of Social Services (DSS). PA 18-76 is effective July 1, 2018.
Currently, DSS may conduct audits of providers participating in Connecticut’s Medicaid program for a number of reasons, including to ensure the integrity of the Medicaid program and to identify overpayments. Current law requires that, at the commencement of an audit, the auditor must disclose the (1) name and contact information of the auditor(s), (2) audit location (e.g., on-site or through record submission), and (3) manner by which requested information shall be submitted. This new legislation requires DSS to also disclose to the provider the types of information that will be reviewed in the audit.
DSS is prohibited from applying any policy, guideline, bulletin, provision in a manual, or other criteria (collectively, Policies) for the purpose of making determinations in a provider audit, unless such Policies and the respective effective dates were made available to the provider before the provider performed the service included in a claim being audited. PA 18-76 expands current law to explicitly include updated medical payment codes in the list of criteria that DSS auditors are prohibited from using to make determinations, unless the criteria were given to the provider prior to the provision of the service giving rise to the audited claim. As such, if auditors review a claim for a service that was conducted before an update was made to a particular medical payment code, the auditor may not make a determination concerning the service based on the updated payment code.
Current law is silent on the type of documentary proof that DSS must accept as sufficient to prove the existence of a provider’s written order or the delivery of a covered item or service by the provider. This legislation seeks to remedy that lack of clarity on the issue of documentary evidence. PA 18-76 specifies the types of documents a DSS auditor must accept as sufficient proof of a provider’s written order to be: a photocopy, facsimile image, an electronically- maintained document, or original pen and ink document. Similarly, it states that any of the following documents constitute sufficient proof of a provider’s delivery of a covered item or service: a receipt signed by the recipient of the item or service or by a nursing facility representative, or a supplier’s detailed shipping invoice and the delivery service tracking information substantiating delivery. The new legislation also allows the DSS auditor to request additional documentation in certain circumstances such as, but not limited to, illegibility of the documents produced by the provider, instances in which documentary proof is contradicted by other information sources the auditor reviewed, or if the auditor makes a good faith determination that the provider may be engaging in fraud.
Existing law requires DSS to include on its website information on the provider auditing process and methods by which providers can avoid clerical errors. This legislation adds that the DSS website must also set forth DSS’s standard provider audit procedures. Finally, PA 18-76 requires DSS auditors to be experienced in the use and review of electronic medical records and to review any electronic medical record that is associated with a patient chart included in a DSS audit.