NY S04955

Defines key terms for Medicaid audits including "overpayment" (unauthorized payments from fraud, abuse, or mistake), "applicable standards" (laws and regulations in effect when services were provided), and "clerical or minor error" (data entry mistakes, duplicate claims, transposed codes)

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

Mandates that when determining overpayment amounts, the Inspector General must consider the level of payment error, whether errors are minor/clerical, impacts to provider financial solvency, and potential negative effects on access to services

Limits use of extrapolation in audits: if overpayments result from 3 or fewer isolated clerical errors, recoupment is limited to only the affected claims rather than extrapolated across all claims

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 is issued

Expands the annual report requirements to include information on how many audits used extrapolation and requires distribution to additional officials including minority legislative leaders and commissioners of addiction services, mental health, and developmental disabilities