OAR 410-120-1395: Program Integrity

(1) The Oregon Health Authority (Authority) uses several approaches to promote program integrity. These rules describe program integrity actions related to provider payments. Our program integrity goal is to pay the correct amount to a properly enrolled provider for covered, medically appropriate services provided to an eligible client according to the client's benefit package of health care services in effect on the date of service. Types of program integrity activities include but are not limited to the following activities: (a) Medical review and prior authorization processes, including all actions taken to determine the medical appropriateness of services or items; (b) Provider obligations to submit correct claims; (c) Onsite visits to verify compliance with standards; (d) Implementation of Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards to improve accuracy and timeliness of claims processing and encounter reporting; (e) Provider credentialing activities; (f) Accessing federal Department of Health and Human Services database (exclusions); (g) Quality improvement activities; (h) Cost report settlement processes; (i) Audits; (j) Investigation of fraud or prohibited kickback relationships; (k) Coordination with the Department of Justice Medicaid Fraud Control Unit (MFCU) and other health oversight authorities. (2) Providers must maintain clinical, financial and other records, capable of being audited or reviewed, consistent with the requirements of OAR 410-120-1360, Requirements for Financial, Clinical and Other Records, in the General Rules Program, the Oregon Health Plan administrative rules, and the rules applicable to the service or item. (3) The following people may review a request for services or items, or audit a claim for care, services or items, before or after payment, for assurance that the specific care, item or service was provided in accordance with the Division of Medical Assistance Program's (Division) rules and the generally accepted standards of a provider's field of practice or specialty: (a) Authority, Department staff or designee; or (b) Medical utilization and review contractor; or (c) Dental utilization and review contractor; or (d) Federal or state oversight authority. (4) Payment may be denied or subject to recovery if the review or audit determines the care, service or item was not provided in accordance with Division rules or does not meet the criteria for quality or medical appropriateness of the care, service or item or payment. Related provider and Hospital billings will also be denied or subject to recovery. (5) When the Authority determines that an overpayment has been made to a provider, the amount of overpayment is subject to recovery. (6) The Authority may communicate with and coordinate any program integrity actions with the MFCU, DHHS, and other federal and state oversight authorities. (7) The Authority must notify HHS-OIG within 20 working days of any disclosures from the date it receives the information, or takes any adverse action to limit the ability of an individual or entity to participate in its program as provided in 42 CFR 1002.3(b). This includes, but is not limited to, suspension, denials, terminations, settlement agreements and situations where an individual or entity voluntarily with draws from the program to avoid a formal sanction. (8) When the Authority initiates an exclusion under § 1002.210, it must notify the individual or entity subject to the exclusion and other state agencies, the state medical licensing board, the public, beneficiaries, and others as provided in § 1001.2005 and § 1001.2006.