Or. Admin. Code § 333-010-0260

Current through Register Vol. 63, No. 11, November 1, 2024

Section 333-010-0260 - Recovery of Overpayments to Providers Resulting from Review or Audit

(1) If the Center determines that an overpayment has been made to an enrolling or ancillary provider, the Center shall seek to recover the amount of overpayment. The Center may use a statistically valid random sampling, with sufficient sample size allowing a confidence interval of 95 percent to determine if an overpayment has been made.

(2) The amount of the review or audit overpayment to be recovered:

(a) Will be the entire amount determined by the Center;

(b) Is not limited to amounts determined by criminal or civil proceedings; and

(c) Will include interest to be charged at allowable state rates.

(3) The Center shall provide an enrolling provider in writing, by registered or certified mail or in person, notice of an overpayment and a request for repayment of the overpayment, along with documentation to support the amount owed.

(4) An enrolling or ancillary provider shall pay the overpayment amount within 30 calendar days from the date the Center mails the notice of overpayment. A request for a hearing does not change the date the repayment of the overpayment is due.

(5) The Center may extend the 30-day repayment period or accept an offer of repayment terms. Any change in reimbursement period or terms must be documented in writing by the Center.

(6) If the provider disagrees with the Center's determination or the amount of overpayment the provider may:

(a) Appeal the decision by requesting a contested case hearing; or

(b) Request a 100 percent audit of all billings submitted to the Center for heart disease, stroke, and diabetes screenings and services provided during the period in question.

(7) A written request for hearing must be submitted to the Center by the provider within 30 calendar days of the date of the decision affecting the provider. The request must specify the areas of disagreement. Failure to request a hearing or administrative review in a timely manner constitutes acceptance by the provider of the amount of the overpayment.

(8) If a 100 percent audit is requested:

(a) An enrolling or ancillary provider is responsible for arranging and paying for the audit; and

(b) The audit must be conducted by a certified public accountant that is knowledgeable about the Oregon Administrative Rules covering the payments in question, and must be conducted within 120 calendar days of the request to use such an audit in lieu of the Center's random sample.

(9) If the provider refuses to reimburse the overpayment or does not adhere to an agreed upon payment schedule, the Center may:

(a) Recoup future provider payments up to the amount of the overpayment; or

(b) Pursue civil action to recover the overpayment.

(10) The Center may, at any time, change the amount of the overpayment upon receipt of additional information from an enrolling provider. If the Center changes an overpayment amount it will provide written notice to the enrolling provider. Any monies paid to the Center that exceed an overpayment will be refunded to the provider.

(11) The Center may pursue civil action to recover any amounts due and payable to the WW Program.

Or. Admin. Code § 333-010-0260

PH 1-2009, f. & cert. ef. 2-13-09; PH 12-2014(Temp), f. & cert. ef. 4-18-14 thru 10-15-14; PH 27-2014, f. & cert. ef. 10-10-14

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042, 431.250