General Laws of Massachusetts - Chapter 118E Division of Medical Assistance - Section 38 Submission of bills by providers; appeals for erroneous denials; overpayments; civil collection actions

Section 38. Providers shall submit to the division a bill for goods sold and services rendered not later than ninety days after the goods are sold or the services rendered, and the division shall verify no less than ten percent of said bills with the recipient of said goods or services. The division shall require that the provider maintain proof, subject to audit, of the actual delivery to recipients of services and goods for which bills are submitted. The division shall verify the accuracy of bills submitted under this section through the application of statistical sampling methods.

Said bills shall be signed under the penalties of perjury; provided, however, that an institution, as defined in clause (c) of section eight, may, in lieu of this requirement, agree in writing with the commissioner that its books and records will be available for inspection at all reasonable times by the division with respect to services rendered under the medical assistance programs administered by the division. The division may establish regulations which provide exceptions to the ninety day billing limitation. Said regulations shall not permit payment of such bills submitted more than one year after the last day of the month in which the goods are sold or the services are provided.

The division may also promulgate regulations which establish procedures for providers to appeal erroneous denials by the division of a provider’s claim for payment under this chapter. Such procedures may: (1) provide for disposition of such appeal by a board comprised of division personnel with expertise in claims processing; (2) provide for summary disposition of such appeal based on a review of written submissions; and (3) require that such appeals be filed with the division within thirty days, or some other time period specified by the division, after the date that the division notifies the provider of the final denial of the claim for payment. The provider’s right to payment under this chapter shall be extinguished if the provider fails to file an appeal within the time prescribed by the division.

When the division has reason to believe that a provider has received payment to which he is not entitled, the division shall notify the provider of the facts on which it bases its belief, identifying the amount believed to have been overpaid and the reasons therefor, and shall accord the provider a reasonable opportunity to submit additional data and argument to support the provider’s claim for reimbursement. After consideration and review of any such information submitted by the provider, the division shall make a final determination. Any amount determined to have been overpaid shall be recoverable under the provisions of this section unless the provider files a timely claim for an adjudicatory hearing raising a material dispute of fact or law. In such adjudicatory hearing, the burden shall be on the provider to demonstrate his entitlement to the payments denied by the division. After such hearing, the commissioner shall notify the provider of his decision with reasons therefor. The decision of the commissioner shall be final and is enforceable under this section unless stayed pursuant to a court order; provided, however, that the division has given written notice of the entry and filing provisions of this section to the provider prior to any notification from the division that it has reason to believe that the provider has received a payment to which he is not entitled. Said written notice shall state that the entry and filing provisions of this section are applicable only to those claims for which the division notifies the provider, subsequent to the date of said written notice, that payments are in dispute.

If the division’s determination, or an administrative review thereof, has become final and the amount overpaid remains unpaid in full or in part, the commissioner may file with the clerk of the municipal court of the city of Boston, or in the district court in the judicial district where the provider has his principal place of business, a certificate or a copy thereof under official seal, stating: the name and address of the provider, the amount owed to the commonwealth as overpayment and in default, that the time in which administrative or judicial review is permitted has expired without appeal having been taken, or, if a claim has been filed under section fourteen of chapter thirty A, that the division’s determination has not been stayed. Upon such filing of a certificate stating said information, such clerk shall assign a civil docket number to such certificate and enter judgment thereon in the civil docket as in a civil action. Such entry shall include the name of the provider identified in the certificate, the amount of such overpayment in default, and the date such certificate is filed. Such certificate shall be enforceable in the same manner and to the same extent as a judgment entered by a court of competent jurisdiction; provided, however, that the rules of court governing procedures in civil cases after the entry of judgment shall not apply to certificates entered as judgments as provided herein. Retroactive rate adjustments made to the rates of institutional providers pursuant to section thirty-two of chapter six A shall not be subject to the filing and entry dispositions of this section.

No physician shall submit a claim for goods or services rendered if said physician is a salaried employee of a hospital and the hospital submits a claim for such goods or services.

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Last modified: September 11, 2015