2019 Georgia Code
Title 49 - Social Services
Chapter 4 - Public Assistance
Article 7 - Medical Assistance Generally
§ 49-4-151.1. Errors or omissions in reporting; right to hearing; exclusion
(a) Any clerical or record-keeping error, including but not limited to a typographical error, scrivener's error, or computer error; any unintentional error or omission in billing, coding, or required documentation; or any isolated instances of incomplete documentation by a provider of medical assistance regarding reimbursement for medical assistance may not in and of itself constitute fraud or constitute a basis to recoup payment for medical assistance provided, so long as any such errors or instances do not result in an improper payment. An improper payment includes any payment that was made to an ineligible recipient, payment for noncovered services, duplicate payments, payments for services not received, payments that are for the incorrect amount, and instances when the department is unable to discern whether a payment was proper because of insufficient or lack of documentation. The department or its agents shall not recoup the cost of medical assistance if such error, omission, or incomplete documentation has been resolved in accordance with subsection (b) of this Code section; provided, however, that recoupment shall be allowed to the extent that the error, omission, or incomplete documentation resulted in an improper payment, though recoupment shall be limited to the amount improperly paid.
(b) A provider of medical assistance shall be allowed 30 calendar days following receipt by the provider of a preliminary audit review report in which to submit records or documents to correct an error or omission or to complete documentation identified in such review report; provided, however, that the department or its agents, in the discretion of the department, may reject the submission of a corrected record or document if the submission would result in an improper payment, or the provider demonstrates a pattern of repeated errors, omissions, or incomplete documentation. The department shall be authorized to establish rules and regulations delineating what constitutes a pattern of repeated errors, omissions, or incomplete documentation taking into consideration the type of provider; frequency of audits; volume of claims submitted by a provider; type of error, omission, or incomplete documentation; and other pertinent factors.
(c) A provider of medical assistance shall be afforded the right to a hearing in accordance with Code Section 49-4-153 for any attempted withholding of reimbursement or recoupment by the department or its agents relating to an error, omission, incomplete documentation, or improper payment relating to the provision of medical assistance.
(d) This Code section shall not apply to criminal or civil investigations which involve fraud, willful misrepresentation, reckless disregard, or abuse conducted by the Attorney General's Medicaid Fraud Control Unit or other law enforcement agencies.
Code 1981, § 49-4-151.1, enacted by Ga. L. 2017, p. 219, § 2/HB 206.
