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(1) Upon receipt of the cost report, the department will instruct the Medicare intermediary to consider Medicaid data when they perform a desk review or audit of the cost report and determine whether a Medicaid overpayment or underpayment has resulted.

(2) For cost reporting purposes where the department finds that an overpayment has occurred, the department will notify the provider of the overpayment.

(a) The provider will have 60 days from the date of the initial notification to repay the amount of the overpayment or to have an agreed upon repayment schedule. If the provider does not repay the whole overpayment within 60 days or defaults on a payment schedule, the department will withhold any future payments the state of Montana makes to the provider. Recovery will be undertaken even though the provider disputes in whole or part the department's determination of the overpayment and requests a fair hearing.

(b) The amount of the overpayment constitutes a debt due the department as of the date of the initial notification to the provider and may be recovered from any person, party, transferee, or fiduciary who has benefited from either the payment or from the transfer of assets.

(3) For cost reporting purposes in the event an underpayment has occurred, the department will reimburse the provider within 60 days from the date of the initial notification to the provider.

(4) When the upper payment limit has been exceeded based on filed cost reports the department will recover the overpayment amount. The department will collect overpayments using the following methodology:

(a) the costs of all facilities that are over the upper payment limit will be divided by the total amount to be collected; and

(b) the percentage in (a) will be multiplied by each facility's total costs to determine the recoverable amount.

(5) Providers aggrieved by adverse determinations by the department may request an administrative review and fair hearing as provided in ARM 37.5.304, 37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313, 37.5.316, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334, and 37.5.337.

History: 2-4-201, 53-2-201, 53-6-113, MCA; IMP, 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 2004 MAR p. 482, Eff. 2/27/04; AMD, 2007 MAR p. 1680, Eff. 10/26/07; AMD, 2010 MAR p. 1534, Eff. 7/1/10; AMD, 2014 MAR p. 1415, Eff. 7/1/14.

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