Conn. Agencies Regs. § 17a-453a-16

Current through October 16, 2024

Section 17a-453a-16 - Audit

(a) DMHAS or its designated agent may conduct audits of a contracted provider's clinical, programmatic, fiscal or other records to verify the accuracy of the contracted provider's claims for payment and the contracted provider's compliance with state and federal law and the contracted provider contract. Audits shall be conducted when care has been authorized, claims have been paid or when DMHAS deems it necessary to carry out its responsibilities under state or federal law.

(b) Audits may include, but are not limited to, review of the following:

(1) The contracted provider's claim(s) for payment;

(2) The covered behavioral health services delivered by the contracted provider to an eligible recipient;

(3) The contracted provider's credentialing or re-credentialing information;

(4) The contracted provider's information supplied to DMHAS regarding a request for reconsideration of contract termination;

(5) The contracted provider's compliance with state and federal law and the provider contract; and

(6) Whether the contracted provider has engaged in any fiscal irregularities.

(c) The contracted provider shall maintain records and permit DMHAS access to records as follows:

(1) All financial records related to delivery of covered behavioral health services to eligible recipients for a period of not less than three (3) years after the date of expiration or termination of the GABHP contract;

(2) Eligible recipient's medical, behavioral health service or other records;

(3) Fiscal records and financial statements;

(4) Copies of all eligible recipients records in order to carry out its audit responsibilities; and

(5) A copy of any audit report prepared by an organization other than DMHAS.

(d)Audit methodology:

DMHAS shall select the contracted providers to audit, define the scope of the audit and establish the frequency of audits based on consideration of factors that may include, but are not limited to, any the following:

(1) Quality of clinical documentation;

(2) Volume of claims for payment submitted or paid;

(3) Type of claims for payment submitted or paid;

(4) Quality-of-care concerns;

(5) Service type;

(6) Geographic area; and

(7) Such other factors as deemed appropriate by DMHAS.

(e)Audit Resolution:

(1) When the audit is completed, DMHAS shall send the contracted provider a copy of the draft audit report. The contracted provider shall be given the opportunity to meet with a DMHAS representative in an exit conference to discuss the findings noted in the draft audit report;

(2) During the exit conference, the contracted provider may submit additional documentation to DMHAS as a result of the findings noted in the draft audit report or the contracted provider may request to submit such documentation subsequent to the exit conference. The contracted provider shall submit all such documentation to DMHAS not later than thirty (30) calendar days after the exit conference. DMHAS shall not consider documentation that is not submitted on time; and

(3) DMHAS shall send the contracted provider a copy of the final audit report with DMHAS's recommendations and a statement of the proposed audit adjustments, if any.

(f)Corrective Action:

(1) Not later than ten (10) business days after receipt of the DMHAS final audit report, the contracted provider shall submit to DMHAS a corrective action plan to address adverse audit findings, if any, included in the DMHAS final audit report. The corrective action plan shall contain the following elements:

(A) The name, address and telephone number of the contracted provider's staff person responsible for ensuring that corrective action is implemented;

(B) A detailed description of the corrective action planned; and

(C) The anticipated completion date of the corrective action.

(2) If the DMHAS final audit report includes information that indicates a threat to the health or welfare of an eligible recipient, the contracted provider shall initiate corrective action not more than 24 hours following such notification; and

(3) If the contracted provider does not agree with the audit findings or believes corrective action is not required, then the corrective action plan may include a statement to that effect and specific reasons in support of such opinion.

(g)Recovery of overpayment:

(1) If audit adjustments require recovery of excess payments made to the contracted provider, DMHAS may adjust any payment currently due the contracted provider by DMHAS or its designated agent; and

(2) If audit adjustments require recovery of excess payments made to a contracted provider who is not currently under contract with DMHAS, recovery shall be sought in an action brought by the state of Connecticut against the contracted provider.

(h)Progressive sanctions for non-compliance with GABHP standards:

A contracted provider who, as a result of an audit, is found to be out of compliance with the provisions as specified in sections 17a-453a-1 to 17a-453a-19, inclusive, of the Regulations of Connecticut State Agencies shall be subject to progressive sanctions as may be determined by the commissioner, including but not limited to, the following:

(1) Reduction in the number of referrals made to the contracted provider for one or more levels of care;

(2) Reduction in the capacity for which DMHAS contracts with the contracted provider for one or more levels of care;

(3) Suspension of referrals made to the contracted provider for one or more levels of care;

(4) Termination of the contracted provider's credentials for one or more levels of care;

(5) Termination of the contracted provider's contract under the GABHP; and

(6) Such other sanctions as the commissioner deems appropriate.

Conn. Agencies Regs. § 17a-453a-16

Adopted effective December 7, 2009