The Office of Quality Assurance

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These audit protocols are being published on the Department of Social Services’ (the “Department”) Internet website in accordance with subdivision (11) of subsection (d) of section 17b-99 of the Connecticut General Statutes.  The purpose of the protocols is to assist the medical provider community in developing programs to improve compliance with Medicaid requirements under state and federal law.  Audit protocols are intended solely as guidance in this effort.  As provided in subdivision (11) of subsection (d) of section 17b-99 of the Connecticut General Statutes, these audit protocols “may not be relied upon to create a substantive or procedural right or benefit enforceable at law or in equity by any person, including a corporation,” and do not constitute rulemaking by the Department.  Nothing in the audit protocols alters any statutory or regulatory requirements.  In the event of a conflict between statements in the protocols and either statutory or regulatory requirements, the requirements of the statutes and regulations govern.

A Medicaid provider’s legal obligations are governed by applicable federal and state law.  Audit protocols do not encompass all the current requirements for payment of Medicaid claims for a particular category of service or provider type and, therefore, are not a substitute for a review of the statutory and regulatory law.

Audit protocols are applied to a specific provider or category of service in the course of an audit and involve the Department’s application of articulated Medicaid agency policy and the exercise of agency discretion.  The Department, consistent with state and federal law, may pursue civil and administrative enforcement actions against any individual or entity that engages in fraud, abuse, or illegal or improper acts or unacceptable practices perpetrated within the medical assistance program.  

The Department will amend its audit protocols as necessary.  Reasons for amending protocols include, but are not limited to, responding to court or administrative decisions, directives from the Centers for Medicare and Medicaid Services or statutory or regulatory changes.

 

Audit Process

The Department’s audit process is governed by subsection (d) of section 17b-99 of the Connecticut General Statutes.  Provided below is a summary of the process, although providers are encouraged to review section 17b-99 in its entirety to gain a more complete understanding of the audit process.
• The Department will give the provider written notification of not less than thirty days prior to the commencement of an audit, unless the Department determines that the health or safety of a recipient of services is at risk or the provider is engaging in vendor fraud. The written notification will include the statistically valid sampling and extrapolation methodology to be used for the audit.
• The provider has at least thirty days to provide documentation in connection with any discrepancy discovered and brought to the attention of such provider in the course of any such audit.
 
• The Department will provide a preliminary written report of the audit to the provider that was the subject of the audit not later than sixty days after the Department determines that the preliminary fieldwork, review and analysis of the audit has concluded.
 
• Following the issuance of the preliminary written report, the Department will hold an exit conference with the provider for the purpose of discussing the preliminary report.
 
• The Department will produce a final written report concerning the audit.  The final written report will be provided to the provider not later than sixty days after the date of the exit conference, unless the Department agrees to a later date or there are other referrals or investigations pending concerning the provider.
 
• A provider aggrieved by a decision contained in the final written report may, not later than thirty days after receipt of the final report, request, in writing, a contested case hearing in accordance with Chapter 54.  Such request shall contain a detailed written description of each specific item of aggrievement.  
 
• A designee of the Commissioner of Social Services shall preside over the hearing.  The designee shall be impartial and shall not be an employee of the Department’s Office of Quality Assurance or an employee of an entity with which the Department contracts for the purpose of auditing a provider in accordance with section 17b-99.  The Commissioner’s designee who presides over the hearing shall issue a final decision not later than ninety days following the close of evidence or the date on which final briefs are filed, whichever occurs later.