SB788 Summary

• Amends the Medicaid Fairness Act to clarify that appeals of adverse decisions must be heard by independent administrative law judges employed by the Department of Health, rather than by the Department of Human Services.

• Expands the definition of "adverse decision" to include payment amounts from gain sharing, risk sharing, incentive payments, and other reimbursement mechanisms, and clarifies that monetary penalties are not required if there is a direct monetary consequence.

• Strengthens provider protections by restricting recoupment based on technical deficiencies unless required by federal law, and prohibits denying subsequent claims based solely on denial of a prior claim without establishing the subsequent claim is also deficient.

• Establishes that if the Department of Human Services grants prior authorization for services, it cannot later claim services were not medically necessary unless the authorization was based on misrepresentation or material circumstances changed.

• Creates audit timelines requiring audit reports within 150 days of field work completion and administrative reconsideration results within 60 days, with no enforcement of adverse decisions if timelines are missed unless good cause is shown.

• Allows providers to appeal termination decisions directly to circuit court without exhausting administrative remedies and provides for injunctive relief to preserve Medicaid participation pending court determination.