Bill > S04955

This bill requires the Medicaid Inspector General to follow specific standards when auditing and reviewing funds for the medical assistance program, which is a government program that provides healthcare to low-income individuals. The bill defines "overpayment" as any amount not authorized under the program, including those resulting from errors, fraud, or abuse. It also clarifies "applicable standards" as the state laws, regulations, and policies in effect at the time a provider's conduct occurred, and defines "clerical or minor error or omission" to include mistakes like mathematical errors, incorrect data entry, or duplicate claims. The bill mandates that audits and reviews must adhere to these applicable standards, and that the Inspector General must provide providers access to these standards beforehand. Furthermore, the Inspector General must publish audit protocols on their website and, when determining repayment amounts for overpayments, must consider factors such as the severity of errors, whether they are minor, and the potential impact on provider solvency and patient access to care. The bill also outlines requirements for sampling methodologies, limits the recovery of funds for isolated clerical errors, and details the information that must be included in draft and final audit reports, including explanations of any extrapolation methods used. Providers will have a minimum of sixty days after a final audit report or hearing determination before recoupment of overpayments begins, and the Inspector General must consider supporting documentation from providers, explaining any rejections in writing. Finally, the bill amends reporting requirements for the Inspector General to include information on the use of extrapolation in audits and the steps taken to comply with considerations for quality of care and patient interests in enforcement actions.

Budget and Finance, Health and Social Services

https://www.nysenate.gov/legislation/bills/2025/S4955