Bill > S04955

This bill requires the Medicaid Inspector General (IG) to follow specific standards when auditing and reviewing medical assistance program funds. The bill defines key terms like "overpayment" (any unauthorized payment due to errors, fraud, or mistakes), "applicable standards" (state laws and regulations in effect when services were provided), and "clerical or minor error" (simple mistakes like data entry errors or duplicate claims). The legislation establishes detailed requirements for conducting audits, including that the IG must: publish audit protocols in advance, provide providers with applicable standards before an audit, consider factors like financial impact and service access when determining overpayments, use statistically sound sampling methods, limit recoupment for isolated minor errors, provide detailed draft audit reports explaining sampling methodologies, consider provider-submitted supporting documentation, and include a specific explanation of audit findings. The bill also modifies the annual reporting requirements for the IG, mandating more comprehensive reporting about audit activities, including details about audit outcomes, recoveries, and efforts to balance enforcement with maintaining quality healthcare services. These changes aim to create more transparent, fair, and balanced medical assistance program audits, protecting both state interests and healthcare providers. The act is set to take effect on April 1, 2026.

Budget and Finance, Health and Social Services

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