(a) The Inspector General or a contractor or an agent of the Inspector General that conducts an audit under this subtitle in which extrapolation may be used shall:
(1) Perform the audit in accordance with a methodology used by the federal government or conducted in accordance with Generally Accepted Auditing Standards (GAAS) and the Statement on Accounting Standards (SAS);
(2) Use a statistically valid sampling methodology; and
(3) Meet the following qualifications:
(i) Have at least 3 years of auditing experience;
(ii) Have experience in the procedural coding program used for the claim;
(iii) Be familiar, either independently or through training by the provider, with the format and content of paper and electronic medical records and claim forms used by the provider; and
(iv) Have general knowledge of the particular health care item or service that is the subject of the audit and the program rules that govern the health care item or service at the time the item or service was provided.
(b) (1) If the medical necessity of the claim is the subject of the audit, the entity that conducts the audit shall include as part of the audit team an individual licensed in the same health occupation as the provider.
(2) The individual included in the audit team under paragraph (1) of this subsection shall have significant knowledge of the audited procedure but is not required to be in the same specialty or practice area as the audited provider.
Structure Maryland Statutes