Joint Budget Committee. The bill makes the following changes
to the reviews and audits of the payments by the department of health care policy and financing (department) to providers:
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The department shall review and audit underpayments and overpayments to providers;
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If the department determines that an overpayment occurred because services could have been provided at a lower cost setting, the overpayment is the difference between the amount paid and the amount due if the services had been provided under other circumstances;
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Any overpayment review evaluating medical necessity must be conducted by a Colorado physician relying only on the information available at the time of treatment;
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The department shall not declare the existence of an overpayment until providers have exhausted all administrative and judicial remedies;
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If the department determines that there has been an underpayment, the department shall pay the provider the amount due because of the underpayment, plus interest;
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Reimbursement for covered services, including amounts collected for an overpayment, must be in an amount adequate to ensure access to care;
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Audits and reviews must not occur more than 3 years after the date the claim was filed;
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Notices of adverse action that fail to comply with department rules are void;
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In an appeal of a determination of overpayment or underpayment, an administrative law judge's ruling must be published on the department's website and other administrative law judges may rely on previous rulings as precedent;
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The department shall annually identify billing errors common across multiple providers to enable providers to correct the errors;
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The department may contract with a qualified agent to review or audit payments to providers for both overpayments and underpayments and must protect against conflicts of interest;
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In any contingency-based contract for review or audit of payments, the compensation must not exceed 12.5% of the amount of overpayments collected and the amount due because of underpayments determined;
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At least quarterly, the department shall publish on its website an audit activity report detailing current and recently completed audits and reviews and summaries of the findings of such audits and reviews and a copy of the contracts, scopes of work, and information regarding supervision of contractor deliverables for audits and reviews;
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The department shall create a provider advisory group to advise the department on issues that providers have concerning the audits and reviews; and
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The department shall contract for an independent review of reviews and audits conducted from the 2018-19 to the 2022-23 state fiscal years for compliance with coding practice standards and state law.
