Section 182-502A-0401. Program integrity activities.

(1) Form. Program integrity activities include:

(a) Conducting audits;

(b) Conducting reviews;

(c) Conducting investigations;

(d) Initiating and reviewing entity self-audits under WAC 182-502A-0501;

(e) Applying algorithms to claim or encounter data;

(f) Conducting unannounced on-site inspections of entity locations; and

(g) Verifying entity compliance with applicable laws, rules, regulations, and agreements.

(2) Location. Program integrity activities may occur:

(a) On the premises of the medicaid agency;

(b) On the premises of the entity.

(3) Timing. The agency may commence program integrity activities concerning any current or former agency-contracted entity or agent thereof at any time up to six years after the date of service.

(4) Notice. Hospitals are entitled to notice as described in RCW 70.41.045(4).

(5) Selecting information to evaluate.

(a) The agency may evaluate any information relevant to validating that the payee received only those funds to which it is legally entitled. In this chapter, "relevant" has a meaning identical to Federal Rule of Evidence 401.

(b) The agency may select information to evaluate by:

(i) Applying algorithms;

(ii) Data mining;

(iii) Claim-by-claim review;

(iv) Encounter-by-encounter review;

(v) Stratified random sampling;

(vi) Nonstratified random sampling; or

(vii) Applying any other method, or combination of methods, designed to identify relevant information.

(6) Collecting records to evaluate. The entity must submit a copy of all records requested by the agency.

(a) The entity must submit requested records to the agency within the time frame stated in the request.

(b) If an entity fails to timely comply with the request, the agency may:

(i) Deny the entity's claim under a prepay review process;

(ii) Issue a draft audit report or preliminary review notice; or

(iii) Issue a final audit report or notice of improper payment.

(c) An entity that fails to timely comply with a request under (a) of this subsection has no right to contest at an administrative hearing an agency action taken under (b)(i) of this subsection.

(d) The entity must submit records electronically unless the agency has given the entity written permission to submit the records in hard copy.

(e) Once a program integrity activity has commenced, the entity must retain all original records and supportive materials until the program integrity activity is completed and all issues resolved, even if the period of retention extends beyond the required six-year period.

(7) Evaluating information.

(a) The agency may evaluate relevant information by applying any method or combination of methods reasonably calculated to determine whether an entity has complied with an applicable law, regulation, or agreement.

(b) Upon request, the entity is entitled to a description of the method or combination of methods used by the agency under subsection (5) of this section.

(8) Nonbilled services. Nonbilled services include any item, drug, code, or payment group that a provider does not submit on the provider's claim to the agency or contractor. When calculating improper payments, the agency does not include nonbilled services in its calculations.

(9) Conducting on-site audits. The agency may conduct on-site audits at any entity location.

(a) During an on-site audit, the agency may create a copy of an entity's records that are potentially relevant to the audit.

(b) Failure to grant the agency access to the premises constitutes failure to comply with a program integrity activity.

(10) Conducting interviews. The agency may interview any person it reasonably believes has relevant information under subsection (5) of this section. Interviews may consist of one or more sessions.

(11) Costs. The agency does not reimburse the costs an entity incurs complying with program integrity activities.

(12) Conducting site visits. The agency may conduct unannounced on-site inspections of any entity location to determine whether the entity is complying with all applicable laws, rules, regulations, and agreements.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0401, filed 12/19/14, effective 1/19/15.]

RCW 41.05.021 and 41.05.160. WSR 15-01-129, § 182-502A-0401, filed 12/19/14, effective 1/19/15.

Rules

182-502A-0501,