NY A01069

Defines key audit terms including "overpayment" (any unauthorized medical assistance payment due to improper claiming, fraud, abuse, or mistake), "applicable standards" (state laws and regulations in effect at the time of service), and "clerical or minor error" (mathematical mistakes, transposed codes, data entry errors)

Requires the Medicaid Inspector General to publish audit protocols on their website before commencing audits and provide providers access to applicable standards prior to any review

Limits extrapolation in audits when clerical or minor errors are isolated occurrences (three or fewer), restricting recoupment to only the affected audited claims in those cases

Mandates draft audit reports include detailed explanations of extrapolation methodology, including sample size, sampling methodology, universe of claims, confidence levels, and calculation steps for alleged overpayments

Prohibits recoupment or repayment from beginning earlier than 60 days after the final audit report or, if a hearing is requested, 60 days after the hearing determination

Expands annual reporting requirements to include information on how many audits used extrapolation and a narrative on steps taken to consider quality and availability of care in enforcement actions, effective April 1, 2026