Montana Code Annotated 2023



Part 1. Medical Assistance -- Medicaid

Department Charged With Administration And Supervision Of Medical Assistance Program -- Overpayment Recovery -- Sanctions For Fraudulent And Abusive Activities -- Adoption Of Rules

53-6-111. Department charged with administration and supervision of medical assistance program -- overpayment recovery -- sanctions for fraudulent and abusive activities -- adoption of rules. (1) (a) The department may administer and supervise a vendor payment program of medical assistance under the powers, duties, and functions provided in Title 53, chapter 2, and this chapter and that is in compliance with Title XIX of the Social Security Act.

(b) When submitting a claim for reimbursement, a provider or the provider's agent may reasonably rely on written instructions and advice provided by the department pursuant to 53-6-160 and 53-6-1407.

(2) (a) The department is entitled to collect from a provider, and a provider is liable to the department for:

(i) the amount of a payment under this part to which the provider was not entitled if the incorrect payment was the result of the provider's error, except as provided in subsection (3), or if the provider's interpretation of the pertinent rule or billing code is not reasonable; and

(ii) the portion of any interim rate payment that exceeds the rate determined retrospectively by the department for the rate period.

(b) If the decision regarding the amount of a payment to which the provider was not entitled depends on an interpretation of a pertinent rule or billing code, the provider has the burden of proving that its interpretation is reasonable and consistent with:

(i) the information given to providers in any applicable Montana medicaid provider rules or manual, including but not limited to the Coding Resources identified in or incorporated by reference in any applicable Montana medicaid provider rule or manual; and

(ii) any written interpretations by the department that were in existence at the time payment was made to the provider.

(c) In addition to the amount of overpayment recoverable under subsection (2)(a), the department is entitled to interest on the amount of the overpayment at the rate specified in 31-1-106 from the date 30 days after the date of mailing of notice of the overpayment by the department to the provider, except that interest accrues from the date of the incorrect payment when the payment was obtained by fraud or abuse.

(d) The department may collect any amount described in subsection (2)(a) by:

(i) withholding current payments to offset the amount due;

(ii) applying methods and using a schedule mutually agreeable to the department and the provider; or

(iii) any other legal means.

(e) The department may suspend payments to a provider for disputed items pending resolution of a dispute only as allowed under 42 CFR 455.23 as of July 1, 2017.

(f) The fact that a provider may have ceased providing services or items under the medical assistance program, may no longer be in business, or may no longer operate a facility, practice, or business does not excuse repayment under this subsection (2).

(3) In an overpayment determination involving medically necessary services that were provided in accordance with applicable medicaid requirements but were improperly billed, a provider must be allowed to submit a new claim or claim adjustment for the services and the claim or adjustment must be considered to be timely filed if submitted within 60 days of notice of the overpayment determination.

(4) The department shall adopt rules establishing a system of sanctions applicable to providers who engage in fraud and abuse. Subject to the definitions in 53-6-155, the department rules must include but are not limited to specifications regarding the activities and conduct that constitute fraud and abuse.

(5) Subject to subsections (6) and (8), the sanctions imposed under rules adopted by the department under subsection (4) may include but are not limited to:

(a) required courses of education in the rules governing the medicaid program;

(b) suspension of participation in the program for a specified period of time;

(c) permanent termination of participation in the medical assistance program; and

(d) imposition of civil monetary penalties imposed under rules that specify the amount of penalties applicable to a specific activity, act, or omission involving intentional or knowing violation of specified standards.

(6) In all cases in which the department may recover medicaid payments or impose a sanction, a provider is entitled to a hearing under the provisions of Title 2, chapter 4, part 6. The department may not recover an overpayment until all formal hearings and appeals are exhausted except in cases in which the department is investigating a credible allegation that the overpayment was the result of fraud.

(7) (a) If the department or an auditor identifies an underpayment to a provider, the department shall:

(i) notify the provider in writing; and

(ii) within 30 days of identification of the underpayment, pay the provider the additional amount to which the provider is entitled.

(b) If payment depends upon the provider's submission of a new claim or claim adjustment, a new claim or claim adjustment is timely filed if submitted within 60 days of notice of the underpayment.

(8) The remedies provided by this section are separate and cumulative to any other administrative, civil, or criminal remedies available under state or federal law, regulation, rule, or policy.

History: En. Sec. 1, Ch. 325, L. 1967; amd. Secs. 47, 48, Ch. 121, L. 1974; R.C.M. 1947, 71-1511(1); amd. Sec. 1, Ch. 276, L. 1979; amd. Sec. 15, Ch. 354, L. 1995; amd. Sec. 444, Ch. 546, L. 1995; amd. Sec. 2, Ch. 453, L. 2015; amd. Sec. 11, Ch. 82, L. 2017.