OAR 410-136-3320: Audits

(1) The Oregon Health Authority (Authority), the Oregon Secretary of State Audits Division, the Oregon Department of Justice, Medicaid Fraud Control Unit (MFCU) and the federal government may audit the brokerage’s and its subcontractor’s records at least annually. When the Authority determines that an overpayment has been made to a brokerage, the amount of overpayment is subject to recovery. The audit shall include, but is not limited to, the following areas: (a) Financial status; (b) Performance and quality of the service; (c) Efficiency and effectiveness of the program’s operation; and (d) The relationship between the funds provided by the Authority and the amounts expended by brokerages or billed by subcontractors and that the use of funds is reasonable and necessary to provide quality service. (2) The Authority or its designee, the Oregon Secretary of State Audits Division, the MFCU, and the federal government may review the brokerage’s, subcontractor’s or provider’s or driver’s records whenever necessary to verify delivery of service, financial and operational status, and compliance with OARs or to investigate unresolved questions of fact or suspected overpayment. Claim payment may be denied or subject to recovery if medical review, audit, or other post-payment review determines the NEMT service was not provided in accordance with applicable Chapter 410 division 120 and division 136 rules or does not meet the criteria for quality of care or medical appropriateness of the care or payment. (3) As specified by 42 CFR 455.17, brokerages, subcontractors, providers and drivers shall promptly report to the Authority any suspected fraud, abuse, or waste of NEMT services. The Brokerage shall cooperate and require all subcontractors to cooperate in good faith and allow access to all records and its subcontractors and provider’s records to allow federal and state agencies to perform investigations and audits of suspected fraud, abuse, or waste . The brokerages and any subcontractor shall immediately allow access to inspect the premises, physical facilities, and equipment where Medicaid-related activities or work is conducted. (4) If the Authority determines there exists a credible allegation of fraud or abuse the Authority may take the actions necessary including but not limited to suspending or terminating a brokerage, subcontractor, provider, or driver from participation in the medical assistance programs, suspending payments or seeking recovery of payments made, or imposing other sanctions provided under state law or regulations. When directed by the Authority, the brokerages shall immediately suspend payments to a subcontractor, provider, or driver that the State determines there is a credible allegation of fraud in accordance with 42 CFR § 455.23. (5) Brokerages shall not execute contracts with or pay for NEMT services provided by subcontractors, providers or drivers who are currently suspended, debarred, or otherwise excluded from participating in Medicaid, Medicare, CHIP, or who have been convicted of a felony or misdemeanor related to a crime or violation of Title XVIII, XIX, XXI, or XX of the Social Security Act or related laws. The brokerage shall immediately notify the Authority when it identifies an excluded provider (individuals or entities). (6) Brokerages are prohibited from notifying or otherwise discussing any Authority or federal agencies investigation with any person(s) who are the subject of the investigation or taking any action against the person(s) or entity, such as termination of employment or contract, without the written permission of the Authority or MFCU while the investigation is ongoing. (7) Brokerages or subcontractors that are currently subject to sanction by the Authority or the brokerage or subcontractor, a person with ownership or control of the brokerage or subcontractor, or a brokerage’s or subcontractor’s managing employee is excluded, sanctioned or suspended by the federal government or another state from Medicare or Medicaid participation the brokerage or subcontractor is not eligible for enrollment, consistent with OAR 410-120-1400, except when the Agency determines good cause exists, in accordance with 42 CFR 455.23.