Bill > HB786

This bill, concerning the state medical assistance program and provider claim payments, specifically amends and reenacts existing law and enacts new provisions to prohibit a particular practice by managed care organizations, which are entities that manage healthcare services for beneficiaries. The key change is the strict prohibition of "extrapolation," a mathematical process used by managed care organizations to estimate audit findings for a large group of healthcare provider claims based on a smaller sample of reviewed claims. Instead, any adjustments to payments, whether additional payments to providers or refunds to the managed care organization, must be based on the actual overpayment or underpayment found in the audited claims, not on extrapolated estimates. The bill also clarifies that this prohibition cannot be waived by contract, rendering any conflicting contract clauses void, and establishes that if a managed care organization, its vendor, or agent violates these provisions, the department can impose penalties without prior notice of corrective action. Finally, it defines "electronic funds transfer" in the context of federal standards.

Health and Social Services

https://www.legis.la.gov/legis/BillInfo.aspx?s=26rs&b=HB786&sbi=y