Amendments for HB23-1295
House Journal, April 28
11 HB23-1295 be amended as follows, and as so amended, be referred to
12 the Committee of the Whole with favorable
13 recommendation:
14
15 Amend printed bill, strike everything below the enacting clause and
16 substitute:
17 "SECTION 1. In Colorado Revised Statutes, 25.5-4-301, add
18 (3)(a)(IX), (3.5)(c), and (3.7) as follows:
19 25.5-4-301. Recoveries - overpayments - penalties - interest -
20 adjustments - liens - review or audit procedures - repeal. (3) (a) A
21 review or audit of a provider is subject to the following procedures:
22 (IX) FOR AUDITS CONDUCTED PURSUANT TO 42 CFR 455.508, AT
23 LEAST QUARTERLY, THE STATE DEPARTMENT SHALL PUBLISH ON ITS
24 WEBSITE AN AUDIT ACTIVITY REPORT DETAILING CURRENT AND RECENTLY
25 COMPLETED AUDITS AND REVIEWS AND SUMMARIES OF THE FINDINGS OF
26 SUCH AUDITS AND REVIEWS, INCLUDING THE NUMBER AND AMOUNTS OF
27 OVERPAYMENTS AND UNDERPAYMENTS FOUND, THE NUMBER AND
28 RESULTS OF APPEALS, THE AMOUNTS COLLECTED, AND THE ERROR RATES
29 IDENTIFIED. AT LEAST QUARTERLY, THE STATE DEPARTMENT SHALL
30 CONDUCT TRAININGS FOR PROVIDERS AND HOLD STAKEHOLDER MEETINGS
31 REGARDING AUDITS AND REVIEWS. IN ADDITION, WHEN THE STATE
32 DEPARTMENT ENTERS INTO CONTRACTS PURSUANT TO THIS SUBSECTION
33 (3)(a), THE STATE DEPARTMENT SHALL PUBLISH ON ITS WEBSITE A COPY OF
34 THE CONTRACT, SCOPE OF WORK, AND INFORMATION REGARDING
35 SUPERVISION OF CONTRACTOR DELIVERABLES.
36 (3.5) (c) THE STATE DEPARTMENT SHALL CREATE A PROVIDER
37 ADVISORY GROUP FOR RECOVERY AUDITS CONSISTING OF EMPLOYEES OF
38 THE STATE DEPARTMENT AND MEMBERS FROM DIFFERENT PROVIDER
39 GROUPS, INCLUDING PHYSICIANS, HOSPITALS, AND ANY OTHER PROVIDER
40 TYPES DIRECTLY IMPACTED BY AUDITS CONDUCTED PURSUANT TO THIS
41 SECTION, APPOINTED BY THE EXECUTIVE DIRECTOR. THE PROVIDER
42 ADVISORY GROUP SHALL MEET AT LEAST QUARTERLY TO REVIEW
43 QUARTERLY ACTIVITY REPORTS REQUIRED BY SUBSECTION (3)(a)(IX) OF
44 THIS SECTION AND ADVISE THE STATE DEPARTMENT ON ISSUES PROVIDERS
45 EXPERIENCE WITH THE AUDITS AND REVIEWS CONDUCTED PURSUANT TO
46 SUBSECTION (3) OF THIS SECTION.
47 (3.7) (a) DURING THE 2023-24 STATE FISCAL YEAR, THE OFFICE OF
48 THE STATE AUDITOR SHALL CONDUCT AN INDEPENDENT REVIEW OF THE
49 STATE DEPARTMENT'S RECOVERY AUDIT CONTRACTOR PROGRAM
50 PURSUANT TO 42 CAR 455.508 FOR COMPLIANCE WITH REQUIREMENTS OF
51 THE FEDERAL CENTERS FOR MEDICARE AND MEDICAID SERVICES MEDICAID
52 RECOVERY AUDIT PROGRAM, COMPLIANCE WITH CODING PRACTICE
53 STANDARDS, AND STATE LAW. TO THE EXTENT POSSIBLE, THE AUDIT SHALL
54 EXAMINE AND ISSUE POLICY RECOMMENDATIONS TO THE JOINT BUDGET
55 COMMITTEE OF THE GENERAL ASSEMBLY, THE HEALTH AND HUMAN
1 SERVICES COMMITTEE OF THE SENATE, AND THE PUBLIC AND BEHAVIORAL
2 HEALTH AND HUMAN SERVICES COMMITTEE OF THE HOUSE OF
3 REPRESENTATIVES, OR THEIR SUCCESSOR COMMITTEES, REGARDING:
4 (I) THE EFFECTIVENESS AND LEVEL OF THE PAYMENT MODEL USED
5 FOR THE STATE DEPARTMENT'S RECOVERY AUDIT CONTRACTOR,
6 INCLUDING THE LEVEL OF PAYMENTS SUFFICIENT TO MAINTAIN A
7 CONTRACTOR, THE SCOPE OF THE CONTRACT AND DELIVERABLES, AND
8 IMPACTS ON PROVIDERS RELATED TO A CONTINGENCY FEE-BASED SYSTEM
9 SIGNIFICANTLY ABOVE THE FEDERAL STANDARD;
10 (II) THE METHODS AND EFFECTIVENESS OF THE STATE
11 DEPARTMENT'S CURRENT APPROACH TO ADDRESSING PROVIDER CONCERNS
12 REGARDING THE MEDICAID RECOVERY AUDIT CONTRACTOR PROGRAM;
13 (III) THE DESIGN, EFFECTIVENESS, AND METHODS USED BY OTHER
14 STATES IN MEETING THE FEDERAL STANDARD, INCLUDING:
15 (A) AN ASSESSMENT OF REQUIREMENTS IMPOSED BY OTHER
16 STATES IN REGARD TO OVERALL RECOVERY AUDIT CONTRACTOR STAFFING
17 AND QUALIFICATIONS OF REVIEWERS TO ENSURE ALIGNMENT OF SPECIALTY
18 AND SUBSPECIALTY EXPERTISE FOR CONDUCTING INITIAL AUDITS AND
19 FINAL DETERMINATIONS;
20 (B) AN ASSESSMENT OF OTHER STATES' LOOKBACK PERIODS AND
21 THE STATES' RELATIVE FINANCING MECHANISMS;
22 (C) BEST PRACTICES EMPLOYED BY OTHER STATES OR
23 RECOMMENDED BY COLORADO PROVIDERS TO HELP IMPROVE BILLING
24 PRACTICES AND COMPLIANCE AND TO PROVIDE SUPPORT THROUGHOUT THE
25 RECOVERY AUDIT CONTRACTOR PROCESS; AND
26 (D) MODELS FROM OTHER STATES USED TO INCENTIVIZE
27 IDENTIFICATION OF UNDERPAYMENTS, ALONG WITH A FEASIBILITY
28 ASSESSMENT FOR THE USE OF SUCH MODELS IN COLORADO.
29 (IV) IMPLICATIONS FOR PROVIDERS AND THE STATE'S GENERAL
30 FUND OF ADJUSTING THE LOOKBACK PERIOD USED FOR THE RECOVERY
31 AUDIT CONTRACTOR AUDITS. THE OFFICE OF THE STATE AUDITOR SHALL
32 EXAMINE, COMPARE TO OTHER STATES, AND, TO THE EXTENT FEASIBLE,
33 DISAGGREGATED BY DATES OF SERVICE, AUDIT FINDING DATE, AND
34 PROVIDER TYPE:
35 (A) THE NUMBER, PROPORTION, AND VALUE OF CLAIMS REVIEWED,
36 RELATIVE TO TOTAL POTENTIAL CLAIMS SUBJECT TO THE RECOVERY AUDIT
37 CONTRACTOR PROGRAM;
38 (B) THE NUMBER AND PROPORTION OF PROVIDERS IMPACTED BY
39 CLAIM REVIEWS AND CONTESTED PAYMENTS;
40 (C) THE NUMBER, PROPORTION, AND VALUE OF CONTESTED
41 PAYMENTS, INCLUDING UNDERPAYMENTS, OVERPAYMENTS, AND
42 RECOUPMENTS; AND
43 (D) THE NUMBER, PROPORTION, VALUE, AND RESULT OF
44 CONTESTED PAYMENTS BY DISPOSITION STATUS, INCLUDING THOSE
45 RESOLVED THROUGH INTERVIEW REQUESTS PURSUANT TO SECTION
46 25.5-4-301(3)(a)(IV.5), INFORMAL RECONSIDERATIONS, AND APPEALS.
47 (V) PROVIDER ADMINISTRATIVE BURDENS ASSOCIATED WITH THE
48 RECOVERY AUDIT CONTRACTOR PROGRAM;
49 (VI) THE FEASIBILITY OF INCENTIVES FOR UNDERPAYMENT
50 IDENTIFICATION, INCLUDING MODELS FROM OTHER STATES AND METHODS
51 FOR IDENTIFYING UNDERPAYMENTS;
52 (VII) THE IMPACT OF AUDITS ON PROVIDER PARTICIPATION AND
53 ACCESS TO CARE, AND OPPORTUNITIES TO INCREASE MEANINGFUL
54 PROVIDER PARTICIPATION AND ACCESS TO CARE; AND
55
1 (VIII) AN ASSESSMENT OF THE DUPLICATION OF UTILIZATION
2 MANAGEMENT REVIEWS AND APPROVALS, SUCH AS PRIOR AUTHORIZATION,
3 WITH POST-PAYMENT AND AUDIT REVIEWS.
4 (b) THE OFFICE OF THE STATE AUDITOR SHALL CONTRACT WITH AN
5 ENTITY THAT REVIEWS STATE PLANS AND AMENDMENTS SUBMITTED TO
6 THE FEDERAL CENTERS FOR MEDICARE AND MEDICAID SERVICES ON
7 BEHALF OF STATES FOR THE ENTITY TO ASSESS FEDERAL FLEXIBILITIES
8 PURSUANT TO 42 CFR 455.516 THAT COLORADO CAN UTILIZE IN ORDER TO
9 IMPROVE THE RECOVERY AUDIT CONTRACTOR PROGRAM AND ASSIST IN
10 PURSUING THOSE FLEXIBILITIES, WHEN ALREADY AUTHORIZED. THE
11 CONTRACTED ENTITY MUST NOT BE A CONTRACTOR UNDER THE RECOVERY
12 AUDIT CONTRACTOR PROGRAM, NOR A COMPETITOR OF SUCH A
13 CONTRACTOR, NOR A PROVIDER OF SIMILAR PROGRAM INTEGRITY
14 PRODUCTS.
15 (c) THIS SUBSECTION (3.7) IS REPEALED, EFFECTIVE JULY 1, 2025.
16 SECTION 2. Appropriation. For the 2023-24 state fiscal year,
17 $850,000 is appropriated to the legislative department for use by the
18 office of the state auditor. This appropriation is from the general fund. To
19 implement this act, the office may use this appropriation for an
20 independent review of the department of health care policy and
21 financing's recovery audit contractor program and contract services to
22 improve the recovery audit contractor program.
23 SECTION 3. Appropriation. (1) For the 2023-24 state fiscal
24 year, $39,287 is appropriated to the department of health care policy and
25 financing for use by the executive director's office. This appropriation is
26 from the general fund. To implement this act, the office may use this
27 appropriation as follows:
28 (a) $35,277 for personal services, which amount is based on an
29 assumption that the office will require an additional 0.9 FTE; and
30 (b) $4,010 for operating expenses.
31 (2) For the 2023-24 state fiscal year, the general assembly
32 anticipates that the department of health care policy and financing will
33 receive $39,286 in federal funds to implement this act, which amount is
34 subject to the "(I)" notation as defined in the annual general appropriation
35 act for the same fiscal year. The appropriation in subsection (1) of this
36 section is based on the assumption that the department will receive this
37 amount of federal funds to be used as follows:
38 (a) $35,276 for personal services; and
39 (b) $4,010 for operating expenses.
40 SECTION 4. Safety clause. The general assembly hereby finds,
41 determines, and declares that this act is necessary for the immediate
42 preservation of the public peace, health, or safety.".
43
44 Page 1 of the bill, line 102, strike "PROVIDERS." and substitute
45 "PROVIDERS, AND, IN CONNECTION THEREWITH, MAKING AN
46 APPROPRIATION.".
47
48
House Journal, April 29
43 Amendment No. 1, Appropriations Report, dated April 28, 2023, and
44 placed in member's bill file; Report also printed in House Journal,
45 April 28, 2023.
46
47 Amendment No. 2, by Representative Bird:
48
49 Amend the Appropriations Committee Report, dated April 28, 2023, page
50 3, line 28, after "(b)" insert "(I)".
51
52 Page 3, after line 38 insert:
53 "(II) THE CONTRACTED ENTITY SHALL CONSIDER THE FOLLOWING
54 ISSUES:
55
1 (A) WHAT ARE THE IMPACTS ON PROVIDERS AND MEDICAID
2 BENEFICIARIES OF CONTRACTOR CONTINGENCY FEES AND A LOOKBACK
3 PERIOD THAT EXCEEDS FEDERAL STANDARDS FOR MEDICAID RECOVERY
4 AUDIT CONTRACTOR PROGRAMS?
5 (B) USING INFORMATION FROM OTHER STATES OR SIMILAR AUDIT
6 PROGRAMS IN THE PUBLIC AND PRIVATE SECTORS, HOW CAN COLORADO
7 OPTIMIZE STAFFING TO BALANCE POTENTIAL OVERPAYMENT
8 CLAIMS AND MEDICAL NECESSITY REVIEWS?
9 (C) WHAT IS THE LEVEL OF FEDERAL FLEXIBILITY FOR ADJUSTING
10 THE TIMING AND PROCEDURE WHEN ASSESSING WHEN A POTENTIAL
11 OVERPAYMENT IS "IDENTIFIED" OR "DETERMINED", AND HOW COULD
12 MODIFICATIONS TO THAT TIMING OR PROCEDURE IMPROVE THE RECOVERY
13 AUDIT CONTRACTOR PROGRAM?
14 (D) HOW SHOULD THE STATE EVALUATE THE COST BENEFIT
15 ANALYSIS TO DETERMINE WHETHER THE MEDICAID RECOVERY AUDIT
16 CONTRACTOR PROGRAM IS STRIKING THE RIGHT BALANCE BETWEEN
17 ACCOUNTABILITY AND ACCESS TO CARE?
18 (E) WHAT ARE OTHER STATES' BEST PRACTICES IN EXERCISING
19 FEDERAL FLEXIBILITIES IN THE RECOVERY AUDIT CONTRACTOR PROGRAM
20 TO IMPROVE PROVIDER EDUCATION, TRAINING, AND ERROR RATES?".
21
22 Amendment No. 3, by Representative Bird:
23
24 Amend the Appropriations Committee Report, dated April 28, 2023, page
25 1, strike line 3 and substitute:
26
27 ""SECTION 1. Legislative declaration. (1) The general
28 assembly finds that:
29 (a) Medicaid payment reviews and audits ensure the state's
30 resources are safeguarded from fraud, and such reviews and audits must
31 be warranted, effective, and efficient;
32 (b) Compliance with billing standards and stewardship of medicaid
33 funds is federally required and vital to the state budget, and the
34 department of health care policy and financing and providers should work
35 collaboratively to improve the recovery audit contractor program to the
36 betterment of all impacted by it;
37 (c) Providers have identified transparency, accountability, process,
38 and efficiency concerns that have led to administrative burden,
39 questionable recoupments, and considerable litigation as a part of these
40 audits, all of which has the potential to discourage provider participation
41 in the medicaid program, threaten access to care for medicaid enrollees,
42 and increase health equity challenges;
43 (d) Colorado's current recovery audit contractor program differs
44 significantly from the national experience and would benefit from an
45 "education first" approach;
46 (e) It is the policy of this state to promote payments to medicaid
47 providers that are adequate to ensure access to care and consistent with
48 42 U.S.C. sec. 1396a (a)(30)(A); and
49 (f) An audit of the program will identify opportunities to reduce
50 provider administrative burden, improve support for providers engaged
51 in the recovery audit contractor program process, evaluate the impact of
52 recovery audit contractor program audits on provider participation in the
53 medicaid program, increase medicaid billing education to providers to
54 reduce future findings and recoupments, and seek balance between
55 provider accountability, regulatory burden, and fiscal stewardship.
56
1 SECTION 2. In Colorado Revised Statutes, 25.5-4-301, add".".
2
3 Renumber succeeding sections accordingly.
4
5 As amended, ordered engrossed and placed on the Calendar for Third
6 Reading and Final Passage.
7
Senate Journal, May 3
After consideration on the merits, the Committee recommends that HB23-1295 be
amended as follows, and as so amended, be referred to the Committee of the Whole with
favorable recommendation and with a recommendation that it be placed on the Consent
Calendar.
Amend reengrossed bill, page 4, line 15, strike "455.508" and substitute
"455.506".
Page 5, strike lines 10 and 11, and substitute "EXPERIENCE WITH AUDITS OF THE
RECOVERY AUDIT CONTRACTORS PROGRAM.".
Page 5, line 15, strike "CAR 455.508" and substitute "CFR 455.506".