Connecticut 2025 Regular Session

Connecticut House Bill HB07105 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
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3		-	LCO 5443 1 of 7
	3	+	LCO No. 5443 1 of 7
4	4
5	5		General Assembly Raised Bill No. 7105
6	6		January Session, 2025
7	7		LCO No. 5443
8	8
9	9
10	10		Referred to Committee on HUMAN SERVICES
11	11
12	12
13	13		Introduced by:
14	14		(HS)
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17	17
	18	+
18	19		AN ACT CONCERNING FORENSIC AUDITS CONDUCTED BY THE
19	20		DEPARTMENT OF SOCIAL SERVICES.
20	21		Be it enacted by the Senate and House of Representatives in General
21	22		Assembly convened:
22	23
23	24		Section 1. Section 17b-99a of the general statutes is repealed and the 1
24	25		following is substituted in lieu thereof (Effective from passage): 2
25	26		(a) (1) For purposes of this section, (A) "extrapolation" means the 3
26	27		determination of an unknown value by projecting the results of the 4
27	28		review of a sample to the universe from which the sample was drawn, 5
28	29		(B) "facility" means any facility described in this subsection and for 6
29		-	which rates are established pursuant to section 17b-340 ~~[, and]~~ or 17b-7
30		-	~~340d,~~ (C) "universe" means a defined population of claims submitted by 8
	30	+	which rates are established pursuant to section 17b-340 or 17b-340d, 7
	31	+	[and] (C) "universe" means a defined population of claims submitted by 8
31	32		a facility during a specific time period, and (D) "forensic audit" means 9
32	33		an examination of financial records for information or evidence that 10
33	34		may be used to determine compliance with applicable law. 11
34	35		(2) The Commissioner of Social Services shall conduct any audit, 12
35	36		including a forensic audit, of a licensed chronic and convalescent 13
36	37		nursing home, chronic disease hospital associated with a chronic and 14
37		-	convalescent nursing home, a rest home with nursing supervision, a 15 Raised Bill No. 7105
	38	+	convalescent nursing home, a rest home with nursing supervision, a 15
	39	+	Raised Bill No. 7105
38	40
39	41
40		-	LCO 5443 2 of 7
	42	+
	43	+	LCO No. 5443 2 of 7
41	44
42	45		licensed residential care home, as defined in section 19a-490, and a 16
43	46		residential facility for persons with intellectual disability which is 17
44	47		licensed pursuant to section 17a-227 and certified to participate in the 18
45	48		Medicaid program as an intermediate care facility for individuals with 19
46	49		intellectual disabilities in accordance with the provisions of this section. 20
47	50		(b) Not less than thirty days prior to the commencement of any such 21
48	51		audit, the commissioner shall provide written notification of the audit 22
49	52		to such facility, unless the commissioner makes a good -faith 23
50	53		determination that (1) the health or safety of a recipient of services is at 24
51	54		risk; or (2) the facility is engaging in vendor fraud under sections 53a-25
52	55		290 to 53a-296, inclusive. 26
53	56		(c) Any clerical error, including, but not limited to, recordkeeping, 27
54	57		typographical, scrivener's or computer error, discovered in a record or 28
55	58		document produced for any such audit, shall not of itself constitute a 29
56	59		wilful violation of the rules of a medical assistance program 30
57	60		administered by the Department of Social Services unless proof of intent 31
58	61		to commit fraud or otherwise violate program rules is established. In 32
59	62		determining which facilities shall be subject to audits, the Commissioner 33
60	63		of Social Services may give consideration to the history of a facility's 34
61	64		compliance in addition to other criteria used to select a facility for an 35
62	65		audit. 36
63	66		(d) A finding of overpayment or underpayment to such facility shall 37
64	67		not be based on extrapolation unless (1) there is a determination of 38
65	68		sustained or high level of payment error involving the facility, (2) 39
66	69		documented educational intervention has failed to correct the level of 40
67	70		payment error, or (3) the value of the claims in aggregate exceeds two 41
68	71		hundred thousand dollars on an annual basis. 42
69	72		(e) A facility, in complying with the requirements of any such audit, 43
70	73		shall be allowed not less than thirty days to provide documentation in 44
71	74		connection with any discrepancy discovered and brought to the 45
72	75		attention of such facility in the course of any such audit. 46
73		-	~~(f) The commissioner shall produce a preliminary written report 47~~ Raised Bill No. 7105
	76	+	Raised Bill No. 7105
74	77
75	78
76		-	LCO 5443 3 of 7
77	79
	80	+	LCO No. 5443 3 of 7
	81	+
	82	+	(f) The commissioner shall produce a preliminary written report 47
78	83		concerning any audit conducted pursuant to this section and such 48
79	84		preliminary report shall be provided to the facility that was the subject 49
80	85		of the audit not later than sixty days after the conclusion of such audit. 50
81	86		(g) The commissioner shall, following the issuance of the preliminary 51
82	87		report pursuant to subsection (f) of this section, hold an exit conference 52
83	88		with any facility that was the subject of any audit pursuant to this 53
84	89		subsection for the purpose of discussing the preliminary report. Such 54
85	90		facility may present evidence at such exit conference refuting findings 55
86	91		in the preliminary report. 56
87	92		(h) The commissioner shall produce a final written report concerning 57
88	93		any audit conducted pursuant to this subsection. Such final written 58
89	94		report shall be provided to the facility that was the subject of the audit 59
90	95		not later than sixty days after the date of the exit conference conducted 60
91	96		pursuant to subsection (g) of this section, unless the commissioner and 61
92	97		the facility agree to a later date or there are other referrals or 62
93	98		investigations pending concerning the facility. 63
94	99		(i) Any facility aggrieved by a final report issued pursuant to 64
95	100		subsection (h) of this section may request a rehearing. A rehearing shall 65
96	101		be held by the commissioner or the commissioner's designee, provided 66
97	102		a detailed written description of all items of aggrievement in the final 67
98	103		report is filed by the facility not later than ninety days following the date 68
99	104		of written notice of the commissioner's decision. The rehearing shall be 69
100	105		held not later than thirty days following the date of filing of the detailed 70
101	106		written description of each specific item of aggrievement. The 71
102	107		commissioner shall issue a final decision not later than sixty days 72
103	108		following the close of evidence or the date on which final briefs are filed, 73
104	109		whichever occurs later. Any items not resolved at such rehearing to the 74
105	110		satisfaction of the facility or the commissioner shall be submitted to 75
106	111		binding arbitration by an arbitration board consisting of one member 76
107	112		appointed by the facility, one member appointed by the commissioner 77
108	113		and one member appointed by the Chief Court Administrator from 78
109		-	among the retired judges of the Superior Court, which retired judge 79
110		-	shall be compensated for his services on such board in the same manner 80 Raised Bill No. 7105
	114	+	Raised Bill No. 7105
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112	116
113		-	LCO 5443 4 of 7
114	117
	118	+	LCO No. 5443 4 of 7
	119	+
	120	+	among the retired judges of the Superior Court, which retired judge 79
	121	+	shall be compensated for his services on such board in the same manner 80
115	122		as a state referee is compensated for his services under section 52-434. 81
116	123		The proceedings of the arbitration board and any decisions rendered by 82
117	124		such board shall be conducted in accordance with the provisions of the 83
118	125		Social Security Act, 42 USC 1396, as amended from time to time, and 84
119	126		chapter 54. 85
120	127		(j) The submission of any false or misleading fiscal information or 86
121	128		data to the commissioner shall be grounds for suspension of payments 87
122	129		by the state under sections 17b-239 to 17b-246, inclusive, and sections 88
123	130		17b-340 and 17b-343, in accordance with regulations adopted by the 89
124	131		commissioner. In addition, any person, including any corporation, who 90
125	132		knowingly makes or causes to be made any false or misleading 91
126	133		statement or who knowingly submits false or misleading fiscal 92
127	134		information or data on the forms approved by the commissioner shall 93
128	135		be guilty of a class D felony. 94
129	136		(k) The commissioner, or any agent authorized by the commissioner 95
130	137		to conduct any inquiry, investigation or hearing under the provisions of 96
131	138		this section, shall have power to administer oaths and take testimony 97
132	139		under oath relative to the matter of inquiry or investigation. At any 98
133	140		hearing ordered by the commissioner, the commissioner or such agent 99
134	141		having authority by law to issue such process may subpoena witnesses 100
135	142		and require the production of records, papers and documents pertinent 101
136	143		to such inquiry. If any person disobeys such process or, having 102
137	144		appeared in obedience thereto, refuses to answer any pertinent question 103
138	145		put to the person by the commissioner or the commissioner's authorized 104
139	146		agent or to produce any records and papers pursuant thereto, the 105
140	147		commissioner or the commissioner's agent may apply to the superior 106
141	148		court for the judicial district of Hartford or for the judicial district 107
142	149		wherein the person resides or wherein the business has been conducted, 108
143	150		or to any judge of such court if the same is not in session, setting forth 109
144	151		such disobedience to process or refusal to answer, and such court or 110
145	152		judge shall cite such person to appear before such court or judge to 111
146		-	answer such question or to produce such records and papers. 112
147		-	(l) The commissioner shall provide free training to facilities on the 113 Raised Bill No. 7105
	153	+	Raised Bill No. 7105
148	154
149	155
150		-	LCO 5443 5 of 7
151	156
	157	+	LCO No. 5443 5 of 7
	158	+
	159	+	answer such question or to produce such records and papers. 112
	160	+	(l) The commissioner shall provide free training to facilities on the 113
152	161		preparation of cost reports to avoid clerical errors and shall post 114
153	162		information on the department's Internet web site concerning the 115
154	163		auditing process and methods to avoid clerical errors. Not later than 116
155	164		April 1, 2015, the commissioner shall establish audit protocols to assist 117
156	165		facilities subject to audit pursuant to this section in developing 118
157	166		programs to improve compliance with Medicaid requirements under 119
158	167		state and federal laws and regulations, provided audit protocols may 120
159	168		not be relied upon to create a substantive or procedural right or benefit 121
160	169		enforceable at law or in equity by any person, including a corporation. 122
161	170		The commissioner shall establish and publish on the department's 123
162	171		Internet web site audit protocols for: (1) Licensed chronic and 124
163	172		convalescent nursing homes, (2) chronic disease hospitals associated 125
164	173		with chronic and convalescent nursing homes, (3) rest homes with 126
165	174		nursing supervision, (4) licensed residential care homes, as defined in 127
166	175		section 19a-490, and (5) residential facilities for persons with intellectual 128
167	176		disability that are licensed pursuant to section 17a-227 and certified to 129
168	177		participate in the Medicaid program as intermediate care facilities for 130
169	178		individuals with intellectual disabilities. The commissioner shall ensure 131
170	179		that the Department of Social Services, or any entity with which the 132
171	180		commissioner contracts to conduct an audit pursuant to this section, has 133
172	181		on staff or consults with, as needed, licensed health professionals with 134
173	182		experience in treatment, billing and coding procedures used by the 135
174	183		facilities being audited pursuant to this section. 136
175	184		(m) (1) Notwithstanding the provisions of this section, the 137
176	185		commissioner shall not conduct a forensic audit of a facility unless the 138
177	186		commissioner (A) provides the facility with an opportunity to meet with 139
178	187		Department of Social Services representatives and respond to any 140
179	188		financial concerns identified by the commissioner, and (B) makes a good 141
180	189		faith determination that a forensic audit of such facility is necessary to 142
181	190		evaluate such financial concerns. 143
	191	+	Raised Bill No. 7105
	192	+
	193	+
	194	+
	195	+	LCO No. 5443 6 of 7
	196	+
182	197		(2) If a facility receives a written request by the department to 144
183	198		cooperate and assist with a forensic audit, such facility shall provide the 145
184	199		cooperation and assistance requested by the department not more than 146
185		-	ten business days after the date the facility receives such request and 147 Raised Bill No. 7105
186		-
187		-
188		-	LCO 5443 6 of 7
189		-
	200	+	ten business days after the date the facility receives such request and 147
190	201		shall ensure that all facility personnel, financial consultants and 148
191	202		accountants fully cooperate and assist with a forensic audit as may be 149
192	203		necessary, except no facility shall be required to divert facility personnel 150
193	204		from residential care duties and responsibilities to cooperate and assist 151
194	205		with such forensic audit. Any facility that fails to provide such 152
195	206		cooperation and assistance shall be subject to a civil monetary penalty 153
196	207		not to exceed one thousand dollars per business day for each business 154
197	208		day that the facility fails to comply with such written request. A facility 155
198	209		may request a fair hearing on the assessment of any such civil monetary 156
199	210		penalty as an aggrieved person pursuant to section 17b-60. 157
200	211		(3) A facility may be liable to the Department of Social Services for 158
201	212		the costs of a forensic audit of a facility identified by the department as 159
202	213		experiencing a serious financial loss, including, but not limited to, any 160
203	214		reports or subsequent testimony related thereto, provided liability for 161
204	215		such costs shall not exceed one hundred thousand dollars. Such costs, 162
205	216		not to exceed one hundred thousand dollars, may be assessed against 163
206		-	any single facility or in the aggregate if more than one facility is subject 164
	217	+	any single facility, or in the aggregate if more than one facility is subject 164
207	218		to a particular forensic audit. 165
208	219		(n) The Department of Social Services may recover (1) subject to the 166
209	220		provisions of subdivision (3) of subsection (m) of this section, the costs 167
210	221		of any forensic audit conducted pursuant to the provisions of this 168
211	222		section from a facility if such forensic audit identifies material issues 169
212	223		with a facility's internal financial management or the integrity of a 170
213	224		facility's financial statements, or (2) civil monetary penalties assessed 171
214	225		against a facility in accordance with subdivision (2) of subsection (m) of 172
215	226		this section through recoupment of such forensic audit costs or civil 173
216	227		monetary penalties against funds that would otherwise be paid to such 174
217	228		facility for services rendered to recipients of assistance under the 175
218	229		Medicaid program. 176
	230	+	Raised Bill No. 7105
	231	+
	232	+
	233	+
	234	+	LCO No. 5443 7 of 7
	235	+
219	236		This act shall take effect as follows and shall amend the following
220	237		sections:
221	238
222		-	Section 1 from passage 17b-99a ~~Raised Bill No. 7105~~
	239	+	Section 1 from passage 17b-99a
223	240
	241	+	Statement of Purpose:
	242	+	To clarify the definition of a forensic audit, the circumstances under
	243	+	which such an audit will be conducted by the Department of Social
	244	+	Services and costs and penalties for a facility associated with such an
	245	+	audit.
224	246
225		-	LCO 5443 7 of 7
226		-
227		-
228		-	HS Joint Favorable
	247	+	[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except
	248	+	that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not
	249	+	underlined.]
229	250