Obtaining information for investigations and audits

(a) The commissioner, for the purposes of investigating the nature, amount, and extent of services provided to a recipient of medical assistance or auditing information submitted to the department concerning a provider’s entitlement to an amount of medical assistance, is authorized, personally or by his duly authorized representative, to administer oaths and to examine and copy books, papers, records (medical, business, or otherwise), or memoranda of a provider or of any other person possessed of information relating to reimbursable costs claimed by a provider or otherwise relating to the amount of medical assistance to which a provider is entitled. The commissioner may compel such examinations by means of subpoenas issued to require the custodian of such items to produce them for examination. A subpoena may be served by any sheriff, by his deputy, or by any other person not less than 18 years of age. Proof may be shown by return of certificate endorsed on a copy of the subpoena. Subpoenas may also be served by registered or certified mail or statutory overnight delivery, and the return receipt shall constitute prima-facie proof of service. If any person shall fail to obey a subpoena issued and served under this subsection, then upon application of the commissioner, the superior court of the county in which such custodian was required to appear may issue an order requiring such custodian to comply with the subpoena and to produce the subpoenaed documentation. Furthermore, if any provider shall fail to obey a subpoena issued and served under this subsection with respect to any matter concerning a claim for medical assistance, that claim for medical assistance shall not be reimbursed by the Department of Community Health; and, if already reimbursed, the amount of medical assistance reimbursed shall be deducted from any amount of medical assistance which may then be or thereafter become payable to such provider. (b) In the course of conducting investigations and audits, the Department of Community Health may request from any governmental department, board, commission, bureau, or agency information and assistance pertinent thereto. The Department of Community Health shall be entitled to have access to all such pertinent information which is within the custody of any governmental department, board, commission, bureau, or agency. History. Ga. L. 1977, p. 384, § 10; Ga. L. 1999, p. 296, § 24; Ga. L. 2000, p. 1589, § 3. 119 49-4-151.1 SOCIAL SERVICES 49-4-151.1 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 disre120 49-4-151.1 PUBLIC ASSISTANCE 49-4-152.1 gard, or abuse conducted by the Attorney General’s Medicaid Fraud Control Unit or other law enforcement agencies. History. Code 1981, § 49-4-151.1, enacted by Ga. L. 2017, p. 219, § 2/HB 206. 49-4-152. Research and demonstration projects; pilot projects to provide health care coverage and essential health care services; pharmacy assistance programs. Subject to the availability of funds, the Department of Community Health is authorized to enter into agreements with and submit applications to departments and agencies of the government of the United States for purposes of accepting grants, receiving matching funds, and administering such grants and funds for research and demonstration projects pursuant to Title XI, XVIII, XIX, or XXI of the federal Social Security Act of 1935, as amended, or any other provision of federal law, without regard to the factor of state wideness and such other factors as may be required to be waived by the terms of the federal grant. Notwithstanding any other provision of law and subject to the availability of funds, the department is authorized to establish pilot projects to provide health care coverage and access to essential health care services or benefits to the uninsured and underinsured, including but not limited to pharmacy assistance programs. History. Ga. L. 1977, p. 384, § 11; Ga. L. 1999, p. 296, § 24; Ga. L. 2001, p. 1240, § 9.