La. Admin. Code tit. 50 § I-4115

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-4115 - Departmental and Provider Obligations

A. The department, through the secretary, has an obligation, imposed by federal and state laws and regulations, to:

1. review bills and claims submitted by providers before payment is made or after.

a. Payments made by the Medicaid Program are subject to review by DHH, Program Integrity Division, a contractor to DHH, or the fiscal intermediary at anytime to ensure the quality, quantity, and need for goods, services, or supplies provided to or for a recipient by a provider;

b. it is the function of the Program Integrity Division (PID) and the Surveillance and Utilization Review Subsystem (SURS) to provide for and administer the utilization review process within the department;

2. assure that claims review brought under this regulation are not frivolous, vexatious or brought primarily for the purpose of harassment;

3. recognize the need to obtain advice from applicable professions and individuals concerning the standards to be applied under this Chapter;

4. recognize the right of each individual to exercise all rights and privileges afforded to that individual under the law including, but not limited to, the right to counsel as provided under the applicable laws.

B. Providers have no right to receive payment for bills or claims submitted to BHSF or its fiscal intermediary. Providers only have a right to receive payment for valid claims. Payment of a bill or claim does not constitute acceptance by the department or its fiscal intermediary that the bill or claim is a valid claim. The provider is responsible for maintaining all records necessary to demonstrate that a bill or claim is in fact a valid claim. It is the provider's obligation to demonstrate that the bill or claim submitted was for goods, services, or supplies:

1. provided to a recipient who was entitled to receive the goods, services, or supplies;

2. were medically necessary;

3. were provided by, or authorized by, an individual with the necessary qualifications to make that determination; and

4. were actually provided to the appropriate recipient in the appropriate quality and quantity by an individual qualified to provide the good, service or supply; or

5. in the case of a claim based on a cost report, that each entry is complete, accurate and supported by the necessary documentation.

C. The provider must maintain and make available for inspection all documents required to demonstrate that a bill or claim is a valid claim. Failure on the part of the provider to adequately document means that the goods, services, or supplies will not be paid for or reimbursed by the Medicaid program.

D. A person has no property interest in any payments or reimbursements from Medicaid which are determined to be an overpayment or are subject to payment review.

E. Providers, providers-in-fact and others, including recipients, must recognize that they have an obligation to obey and follow all applicable laws, regulations, policies, criteria, and procedures. In the case of an action brought for incorrect submissions, providers and providers-in-fact recognize the department may impose judicial interest on any outstanding recovery or recoupment, or reasonable cost and expenses incurred as the direct result of the investigation or review, including, but not limited to, the time and expenses incurred by departmental employees or agents and the fiscal intermediary's employees or agents.

F. In determining the amount to be paid or reimbursed to a provider any and all overpayments, recoupment or recovery must be taken into consideration prior to determining the actual amount owed to the provider.

La. Admin. Code tit. 50, § I-4115

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 25:1634 (September 1999), repromulgated LR 29:587 (April 2003), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38: 2777 (November 2012).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance Program Integrity Law).