Oklahoma § 56-1011.9 - Establishment of method to reduce payment error rate Reporting of errors

§ 56-1011.9. Establishment of method to reduce payment error rate Reporting of errors

A. 1. The Oklahoma Health Care Authority shall establish a

method to deter abuse and reduce errors in Medicaid billing,

payment, and eligibility through the use of technology and

accountability measures for the Authority, providers, and consumers.

The Authority shall achieve a payment error rate measurement of no

greater than five percent (5%) by fiscal year 2009. The Oklahoma

Health Care Authority shall evaluate and report findings to the

Governor and the Legislature.

2. For the purposes of this section, “error rate” means errors

based on clearly defined objective documentation standards that are

readily available to providers. Training to meet the standards

shall be provided on at least an annual basis by the Oklahoma Health

Care Authority.

B. 1. If errors are suspected to be the result of fraudulent

acts, the errors shall be reported and investigated by the Oklahoma

Attorney General.

Oklahoma Statutes - Title 56. Poor Persons

2. Recoupment of overpayments due to identified errors

determined not to be fraudulent and shall occur only after the

provider has had the opportunity to exercise the right to an appeal

that shall include a hearing conducted by an administrative law

judge appointed by the Oklahoma Attorney General. The provider

shall have the right to participate in the hearing and to be

represented by legal counsel.

C. The Oklahoma Health Care Authority shall evaluate and report

findings concerning the limited use of the extrapolation method to

the Governor and the Legislature.

Added by Laws 2006, c. 315, § 9, emerg. eff. June 9, 2006. Amended

by Laws 2010, c. 375, § 1, eff. Nov. 1, 2010.

§56-1011.9A. Claims payable to providers of Medicaid home and

community-based services — OHCA prohibited from utilizing certain

audit methods — Development and refinement with DOH of audit

methodology.

A. As used in this section:

1. "Error rate" means the percentage of dollars of audited

claims found to be billed in error;

2. "Extrapolation" means the methodology of estimating an

unknown value by projecting, with a calculated precision, i.e.,

margin of error, the results of a probability sample to the universe

from which the sample was drawn;

3. "Probability sample" means the standard statistical

methodology in which a sample is selected based on the mathematical

theory of probability;

4. "Sample" means a statistically valid number of claims

obtained from the universe of claims audited or reviewed; and

5. "Universe" means all paid claims or types of paid claims

audited or reviewed during a specified time frame.

B. For claims payable to providers of Medicaid home and

community-based services submitted on or after January 27, 2020, but

not later than November 1, 2027, the Oklahoma Health Care Authority

shall not use:

1. Extrapolation or any other statistical method for the

auditing of such claims that can result in a determination that a

provider is required to repay any amount paid to such provider in

excess of the amount of the audited claim, regardless of the claims

error rate; or

2. Statistical sampling to audit submitted claims in a manner

that can result in a liability amount in excess of the total amount

of claims used in a statistical sample.

C. The use by the Oklahoma Health Care Authority of any

methodology as described in subsection A of this section prior to

the effective date of this act, and which was performed pursuant to

the provisions of Oklahoma Administrative Code 317:30-3-2.1 with

Oklahoma Statutes - Title 56. Poor Persons

respect to an audit period beginning on or after January 27, 2020,

through November 1, 2025, shall be deemed as invalid and any demand

for payment made to a provider on the basis of such methodology

shall be null and void. The Oklahoma Health Care Authority shall

not have authority to make any demand for repayment from a provider

with respect to an audit the effect of which has been nullified

pursuant to the provisions of this subsection or to impose a

financial penalty upon such provider with respect to any such audit.

D. The Oklahoma Health Care Authority shall comply with the

requirements of Section 249 of Title 56 of the Oklahoma Statutes

with respect to the reporting of alleged fraud.

E. The Oklahoma Health Care Authority and the Department of

Human Services shall work in conjunction to develop and refine an

audit methodology with respect to claims submitted for payment by

providers in the Home and Community Based Waivers related programs.

The agencies shall develop an information and training program so

that affected providers and their authorized agents have an

opportunity to become familiar with the audit standards and have a

clear and consistent set of guidelines with respect to the claims

submission process and any possible audit activity. The joint

program shall be complete and ready for presentation to providers

and their authorized agents not later than November 1, 2027.

Added by Laws 2025, c. 479, § 1, emerg. eff. May 29, 2025.