53-6-1403. Extrapolation and statistical sampling prohibited -- exceptions. (1) Except as provided in subsection (2):
(a) in conducting an initial overpayment audit, the department or an auditor may not use statistical sampling extrapolation for automated reviews and may not rely on extrapolation to determine or support the amount of an overpayment determination; and
(b) an overpayment determination must be based on and supported by evidence of an overpayment for each claim.
(2) In an overpayment audit of a high-risk provider or a followup audit of any provider, the department or an auditor may use statistical sampling extrapolation for an automated review or may rely on extrapolation to determine or support the amount of an overpayment determination.
(3) The department or an auditor may use data analysis techniques to identify claims that are most likely to contain overpayments for purposes of selecting providers or claims for overpayment audits.
History: En. Sec. 3, Ch. 82, L. 2017.
Structure Montana Code Annotated
Title 53. Social Services and Institutions
Chapter 6. Health Care Services
Part 14. Medicaid Overpayment Audits
53-6-1403. Extrapolation and statistical sampling prohibited -- exceptions
53-6-1404. Peer review of overpayment findings
53-6-1405. Audit completion -- notice of overpayment determination -- opportunity to resubmit claim
53-6-1406. Publication of audit results
53-6-1407. Audit education and training
53-6-1408. Applicability to auditor -- scope