Computation of Provider Overpayment by Statistical Sampling

PURPOSE: This rule establishes a statistical methodology where the billing forms or claims for payment submitted by Medicaid providers may be examined to determine compliance with Title XIX (Medicaid) Program requirements and proper payment, and this rule also sets forth the manner in which providers may challenge the results. (1) The following definitions will be used in administering this rule: (A) “Claim for payment” or “claim” means the Internal Control Number (ICN) and the associated data submitted to the Medicaid agency for the purpose of obtaining payment by the Title XIX Medicaid Program; (B) “Disproportionate Stratified Random Sampling Technique” means a sampling method in which the size of the sample drawn from a particular stratum is not proportional to the relative size of that stratum; (C) “Medicaid agency” or “the agency” means the single state agency administering or supervising the administration of the state Medicaid plan; (D) “Overpayment” means an amount of money paid to a provider by the Medicaid agency to which the provider was not entitled by reason of improper billing, error, fraud, abuse, lack of verification, or insufficient medical necessity; (E) “Provider” means any person, partnership, corporation, not-for-profit corporation, professional corporation, or other business entity that enters into a contract or provider agreement with the Medicaid agency for the purpose of providing services to Medicaideligible persons and obtaining from the Medicaid agency reimbursement for services; (F) “Sampling Unit” means one (1) of the units into which an aggregate (e.g. total paid on claims) is divided for the purpose of sampling. For example a sampling unit may be ICNs, a specific procedure code or codes, or participant DCNs (Document Control Numbers); (G) “Stratum” refers to a sampling method in which the universe is divided into nonoverlapping subgroups. Each of the subgroups is called a stratum, and two (2) or more subgroups are called strata; and (H) “Universe” means all claims for payment or all claims relating to a specific service or a specific item or merchandise submitted by a provider between two (2) certain dates. (2) The Medicaid agency may use a Disproportionate Stratified Random Sampling Technique to establish provider overpayments. This technique is an extrapolation of a statistical sampling of claims used to determine the total overpayment for recoupment. (3) When a total overpayment has been computed by statistical sampling, the Medicaid agency may proceed to recover the full amount of the overpayment from the provider as an amount due. Recovery of the overpayment shall be accomplished according to the provisions of 13 CSR 70-3.030(6), except that in cases where the amount due was computed by statistical sampling, the notice informing the provider of the amount due required by 13 CSR 70-3.030(6)(A) and (B) shall also contain the following information: (A) The dates of service and total paid for the Universe; (B) Definition of the sampling unit; (C) The number of claims in the statistical sample; and (D) A generally summarized description of the reasons for the overpayment determinations with all claims in the statistical sample identified as to which overpayment description applies to each. (4) The extrapolated overpayment is a final decision regarding administration of the state Medicaid plan and is subject to appeal in accordance with section 208.156, RSMo. AUTHORITY: sections 208.201 and 660.017, RSMo 2016.* Original rule filed Aug. 28, 2018, effective April 30, 2019. *Original authority: 208.201, RSMo 1987, amended 2007 and 660.017, RSMo 1993, amended 1995.