Or. Admin. Code § 333-010-0175

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

Section 333-010-0175 - Recovery of Overpayments to Providers Resulting from Review or Audit

(1) When the Center determines that an overpayment has been made to a provider, the amount of overpayment is subject to recovery:

(a) To determine the overpayment amount, the Center may use a statistically valid random sampling, with sufficient sample size allowing a confidence interval of 95 percent.

(b) After the Center determines an overpayment amount by the random sampling method set forth in section (1) of this rule, the provider may request a 100 percent audit of all billings submitted to the Center for breast and cervical cancer screening and diagnostic services provided during the period in question. If a 100 percent audit is requested:

(A) Payment and arrangement for a 100 percent audit is the responsibility of the provider requesting 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 audit in lieu of the Center's random sample.

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

(a) Will be the entire amount determined or agreed to 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 will deliver to the provider by registered or certified mail or in person a request for repayment of the overpayment and the documentation to support the alleged amount.

(4) If the provider disagrees with the Center's determination or the amount of overpayment the provider may appeal the decision by requesting a contested case hearing:

(a) 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.

(b) Failure to request a hearing or administrative review in a timely manner constitutes acceptance by the provider of the amount of the overpayment.

(5) The overpayment is due and payable 30 calendar days from the date of the decision by the Center:

(a) An additional 30 day grace period may be granted the provider upon request to the Center;

(b) A request for a hearing does not change the date the repayment of the overpayment is due.

(6) The Center may extend the reimbursement period or accept an offer of repayment terms. Any change in reimbursement period or terms must be made in writing by the Center.

(7) 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.

(8) As the result of a hearing the amount of the overpayment may be reduced in part or in full.

(9) The Center may, at any time, change the amount of the overpayment upon receipt of additional information. Any changes will be verified in writing by the Center. Any monies paid to the Center that exceed an overpayment will be refunded to the provider.

(10) If a provider is terminated or sanctioned for any reason, the Center may pursue civil action to recover any amounts due and payable to ScreenWise BCC.

Or. Admin. Code § 333-010-0175

PH 9-2008, f. & cert. ef. 6-16-08; PH 11-2016, f. & cert. ef. 4/1/2016

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 413.042