HB1314
To Amend The Law Concerning Certain Audits Of Healthcare Providers; And To Create The Arkansas Medical Audit Bill Of Rights Act.
AI-Generated Summary
This bill proposes to create the "Arkansas Medical Audit Bill of Rights Act." It outlines specific rights and procedures for healthcare providers when undergoing audits conducted by insurance companies, third-party payors, or claim administrators. Key provisions include requiring at least one week's notice before an initial audit, ensuring audits involving clinical judgment are conducted with consultation from a peer provider, and stipulating that clerical or recordkeeping errors alone should not be considered fraud without proof of intent. The bill also sets limits on the scope of audits, defining how projected overpayments or underpayments are handled and restricting the number of audits an auditor can initiate per year. Furthermore, it establishes requirements for the timing and content of audit reports, mandates an appeals process for providers, and prohibits the use of extrapolation in calculating recoupments or penalties. The act specifically excludes audits conducted on behalf of the Arkansas Medicaid Program or those involving alleged fraud, willful misrepresentation, or abuse. The Insurance Commissioner is tasked with promulgating rules to implement and enforce this subchapter.
Potential Impact Analysis
Who Might Benefit?
Healthcare providers in Arkansas would be the primary beneficiaries of this bill. It aims to provide them with greater transparency, fairness, and protection during audits conducted by insurance companies and other entities that process claims. By establishing a "Bill of Rights," the legislation seeks to standardize audit procedures, limit the scope and frequency of audits, and offer clearer pathways for recourse and correction of errors. This could lead to reduced administrative burdens, more predictable financial outcomes from audits, and a more equitable auditing process for those providing healthcare services.
Who Might Suffer?
Auditors, which include insurance companies, third-party payors, and claim administration entities, are the groups most likely to be negatively impacted by this bill. The proposed legislation introduces new procedural requirements and limitations that could increase the administrative effort and potentially reduce the recoupment amounts that these entities can recover from healthcare providers. For instance, the notice periods, the requirement for peer consultation in certain audits, limitations on the number of claims audited, and the prohibition of extrapolation could all impact the efficiency and effectiveness of their audit processes. Additionally, the established appeals process and the stricter definitions around what constitutes fraud versus error might present challenges in recouping disputed funds.