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83rd OREGON LEGISLATIVE ASSEMBLY--2025 Regular Session
Senate Bill 61
Sponsored by Senator HAYDEN (Presession filed.)
SUMMARY
The following summary is not prepared by the sponsors of the measure and is not a part of the body thereof subject
to consideration by the Legislative Assembly. It is an editor’s brief statement of the essential features of the
measure as introduced.The statement includes a measure digest written in compliance with applicable readability
standards.
Digest: The Act limits when OHA may claw back moneys paid to Medicaid providers. (Flesch
Readability Score: 63.4).
Prohibits the recovery of reimbursements paid on claims in the medical assistance program if
the provider can verify that the patient visit occurred or the service or item was provided.Pro-
hibits the recovery of reimbursements based on a sample of a provider’s claims unless a similar error
rate is found in a sample of at least 15 percent of the provider’s claims.
Applies to audits of claims for the reimbursement of items or services provided on or after
January 1, 2019, if the claims have not been fully adjudicated.
Declares an emergency, effective on passage.
A BILL FOR AN ACT
Relating to medical assistance provider audits; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. In conducting an audit of provider claims for reimbursement in the medical
assistance program, in accordance with 42 U.S.C. 1396a(a)(42)(B), the Oregon Health Au-
thority or an entity contracting with the authority to perform the audit:
(1) May not recover the reimbursement paid on a claim on the basis that a patient visit
did not occur or that a service or item was not provided during a patient visit, if the provider
submits documentation verifying that the patient visit occurred or the service or item was
provided, including but not limited to:
(a) Treatment or service plans;
(b) Clinical assessments created during a patient visit;
(c) Chart or progress notes;
(d) Patient attestations that the patient received the service or treatment;
(e) Documentation of referrals to other providers; or
(f) Prescriptions written for the patient during the visit.
(2) For a provider’s billing code error on a claim for reimbursement for a behavioral
health service that results in the provider receiving more reimbursement than the provider
was entitled to receive for the service, may recover only the difference between the amount
of reimbursement paid and the amount of reimbursement that would have been paid if the
claim had been properly coded.
(3)(a) Except as provided in paragraph (b) of this subsection, when auditing a sample of
a provider’s claims, may recover only the amount of the improper reimbursement paid on
the specific errors identified in the sample and may not extrapolate the error rate in the
sample to all or any portion of the provider’s claims.
(b) May extrapolate the error rate found in a sample of a provider’s claims if the au-
thority or the contractor conducts a new sampling of at least 15 percent of the provider’s
NOTE:Matter in boldfaced type in an amended section is new; matter [italic and bracketed] is existing law to be omitted.
New sections are in boldfaced type.
LC 2733 SB61
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claims and finds an error rate consistent with the error rate found in the initial sample.
SECTION 2. Section 1 of this 2025 Act applies to audits of claims for the reimbursement
of items or services provided on or after January 1, 2019, if the claims have not been fully
adjudicated through administrative or judicial processes.
SECTION 3.This 2025 Act being necessary for the immediate preservation of the public
peace, health and safety, an emergency is declared to exist, and this 2025 Act takes effect
on its passage.
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