Mont. Admin. R. 37.85.416 - STATISTICAL SAMPLING AUDITS
(1) At
the option of the department, the amount of money erroneously paid to a
provider for any given period of time may be determined by the use of
statistical sampling and extrapolation, rather than by an audit of 100% of the
claims submitted by the provider during the period of time under review.
Statistical sampling and extrapolation shall not be used to determine
overpayments for inpatient hospital services, outpatient hospital services, or
hospital inpatient psychiatric services, or in cases where the number of line
items in the review period does not equal 500 or more.
(a) A line item consists of a single service,
under one procedure rate with one or more units of service, procedure or item
on a Medicaid claim form for which a provider has received payment.
(2) If the department chooses to
use statistical sampling and extrapolation to determine an overpayment, it will
use a statistical method to draw a random sample of claims for the review
period and will audit these claims. The department will calculate the
provider's error rate based on the net dollar amount overpaid to the provider
after any underpayments occurring in the sample have been offset against the
overpayments occurring in the sample. The department will then calculate the
total overpayment for the review period using an appropriate statistical
methodology.
(3) If the department
chooses to use statistical sampling and extrapolation, it shall notify the
provider of its intention to do so. When the sampling and extrapolation process
is completed, the department shall provide the provider with information
regarding the sample size, the sample selection method, and the formulas and
calculations used in the extrapolation.
(4) It is presumed that the overpayment
amount determined by the use of statistical sampling and extrapolation is
correct. However, the provider may rebut this presumption by presenting
evidence that the sampling and extrapolation process used by the department was
invalid, by presenting evidence that claims in the sample determined by the
department to be erroneous or overpaid were correctly paid, or by requesting an
audit of 100% of the claims paid in the review period, as provided in
(5).
(5) A provider who does not
agree with the overpayment amount determined by statistical sampling may
request that the department conduct a 100% audit of the claims paid in the
review period. The request for a 100% audit must be made within 30 days of the
date of the notice informing the provider of the results of the statistical
sampling. The department must then conduct such a review.
(a) If the audit shows an overpayment amount
which is different from the overpayment amount determined by sampling and
extrapolation, the amount determined by the audit shall be used by the
department in assessing an overpayment against the provider. A provider who is
aggrieved by a department determination based upon the results of the audit may
appeal by means of the fair hearing procedures set forth in ARM
37.5.304,
37.5.305,
37.5.307,
37.5.310,
37.5.311,
37.5.313,
37.5.316,
37.5.322,
37.5.325,
37.5.328,
37.5.331,
37.5.334 and
37.5.337.
(b) The provider must pay the department's
costs for such an audit, unless the overpayment amount determined by the 100%
audit is at least 10% less than the overpayment amount determined by the
statistical sample.
(6)
A provider who is aggrieved by an overpayment determined by statistical
sampling and extrapolation may appeal by means of the fair hearing procedures
set forth in ARM 37.5.304, 37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313,
37.5.316, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334 and
37.5.337.
Notes
53-6-113, MCA; IMP, 53-6-101, 53-6-111, MCA;
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