1| STATE OF OKLAHOMA | | | 2| 2nd Session of the 60th Legislature (2026) | | | 3|HOUSE BILL 3342 By: Williams | | | 4| | | | 5| | | | 6| AS INTRODUCED | | | 7| An Act relating to Medicaid audits; creating the | | Oklahoma Medicaid Audit Bill of Rights Act; defining | 8| terms; providing certain protections for health care | | providers; providing for advance notice; providing | 9| for specialty appropriate audit; limiting scope of | | audits; directing for no allowance of extrapolation; | 10| providing for appeals process; providing for | | noncodification; providing for codification; and | 11| providing an effective date. | | | 12| | | | 13| | | | 14|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: | | | 15| SECTION 1. NEW LAW A new section of law not to be | | | 16|codified in the Oklahoma Statutes reads as follows: | | | 17| This act shall be known and may be cited as the "Oklahoma | | | 18|Medicaid Audit Bill of Rights Act". | | | 19| SECTION 2. NEW LAW A new section of law to be codified | | | 20|in the Oklahoma Statutes as Section 5029.10 of Title 63, unless | | | 21|there is created a duplication in numbering, reads as follows: | | | 22| As used in this act: | | | 23| 1. "Audit" means an investigation or review of a claim | | | 24|submitted by a health care provider if the investigation or review: | | | Req. No. 14797 Page 1 ___________________________________________________________________________
1| a. is conducted by an auditor, and | | | 2| b. involves records, documents, or information other | | | 3| than the filed claim; | | | 4| 2. "Auditor" means | | | 5| a. an insurance company, | | | 6| b. a third-party payor, | | | 7| c. the Oklahoma Health Care Authority, or | | | 8| d. an entity that represents a responsible party, | | | 9| including a company or group that administers claims | | | 10| services; | | | 11| 3. "Clerical or recordkeeping error" means a mistake in the | | | 12|filed claim regarding a required document or record, including, but | | | 13|not limited to: | | | 14| a. a typographical error, | | | 15| b. a scrivener's error, or | | | 16| c. a computer error; and | | | 17| 4. "Health care provider" means a person who is licensed, | | | 18|certified, or otherwise authorized by the laws of this state to | | | 19|administer health care services to Medicaid patients. | | | 20| SECTION 3. NEW LAW A new section of law to be codified | | | 21|in the Oklahoma Statutes as Section 5029.11 of Title 63, unless | | | 22|there is created a duplication in numbering, reads as follows: | | | 23| | | | 24| | | | Req. No. 14797 Page 2 ___________________________________________________________________________
1| A. Notwithstanding any other law, when an audit is conducted by | | | 2|an auditor, the audit shall be conducted according to the following | | | 3|bill of rights: | | | 4| 1. An auditor conducting the initial audit shall give the | | | 5|health care provider notice of the audit at least one (1) week | | | 6|before conducting the initial audit for each audit cycle; | | | 7| 2. An audit that involves the application of clinical or | | | 8|professional judgment shall be conducted by or in consultation with | | | 9|a health care provider of the same specialty as the health care | | | 10|provider being audited; | | | 11| 3. A clerical or recordkeeping error shall not: | | | 12| a. constitute fraud, or | | | 13| b. be subject to criminal penalties without proof of | | | 14| intent to commit fraud. | | | 15| A claim arising pursuant to paragraph 3 of this subsection may | | | 16|be subject to recoupment; | | | 17| 4. A finding of an overpayment or underpayment of a filed claim | | | 18|may be a projection based on the number of patients served by the | | | 19|health care provider having a similar diagnosis. | | | 20| Recoupment of claims pursuant to this paragraph shall be based | | | 21|on the actual overpayment unless the projection for overpayment or | | | 22|underpayment is part of a settlement by the health care provider; | | | 23| | | | 24| | | | Req. No. 14797 Page 3 ___________________________________________________________________________
1| 5. When an audit is for a specifically identified problem that | | | 2|has been disclosed to the health care provider, the audit shall be | | | 3|limited to a claim that is identified by a claim number; | | | 4| 6. For an audit other than that described in paragraph 5 of | | | 5|this subsection, the audit shall be limited to the greater of: | | | 6| a. fifty claims, or | | | 7| b. twenty-five one-hundredths of one percent (0.25%) of | | | 8| the number of claims billed by the health care | | | 9| provider to the auditor in the previous calendar year; | | | 10| 7. If an audit reveals the necessity for a review of additional | | | 11|claims, the audit shall be conducted by one of the following methods | | | 12|at the discretion of the health care provider: | | | 13| a. on-site, | | | 14| b. electronically, or | | | 15| c. by the same method as the initial audit; | | | 16| 8. Except for an audit initiated pursuant to paragraph 5 of | | | 17|this subsection, an auditor shall not initiate an audit of a health | | | 18|care provider more than two times in a calendar year; | | | 19| 9. A recoupment shall not be based on: | | | 20| a. documentation requirements in addition to the | | | 21| requirements for creating or maintaining documentation | | | 22| prescribed by state law, rule, federal law or | | | 23| regulation, or | | | 24| | | | Req. No. 14797 Page 4 ___________________________________________________________________________
1| b. a requirement that a health care provider perform | | | 2| professional duties prescribed by state law, rule, | | | 3| federal law, or regulation; | | | 4| 10. Recoupment shall only occur following the correction of a | | | 5|claim and shall be limited to amounts paid in excess of amounts | | | 6|payable under the corrected claim. | | | 7| An auditor may recoup the entire overpaid claim if payment is | | | 8|issued for the corrected claim on the same date. | | | 9| Following a notice of overpayment, a health care provider shall | | | 10|have at least sixty (60) days to file a corrected claim; | | | 11| 11. Approval of a health care service, health care provider, or | | | 12|patient eligibility upon adjudication of a claim shall not be | | | 13|reversed unless the health care provider obtained the adjudication | | | 14|by fraud or misrepresentation of claim elements; | | | 15| 12. Each health care provider shall be audited under the same | | | 16|standards and parameters as other similarly situated health care | | | 17|providers audited by the auditor; | | | 18| 13. A health care provider shall be allowed at least sixty (60) | | | 19|days following receipt of the preliminary audit report in which to | | | 20|produce documentation to address any discrepancy found during the | | | 21|audit; | | | 22| 14. The period covered by an audit shall not exceed twenty-four | | | 23|(24) months from the date the claim was submitted to or adjudicated | | | 24|by an auditor; | | | Req. No. 14797 Page 5 ___________________________________________________________________________
1| 15. The preliminary audit report pursuant to paragraph 13 of | | | 2|this subsection shall be delivered to a health care provider within | | | 3|one hundred twenty (120) days after the conclusion of the audit. | | | 4| A final audit report shall be delivered to the health care | | | 5|provider within six (6) months after the receipt of the preliminary | | | 6|audit report or receipt of the final appeal as provided for in this | | | 7|subsection, whichever is later; and | | | 8| 16. Notwithstanding any other provision in this section, the | | | 9|auditor conducting the audit shall not use the accounting practice | | | 10|of extrapolation in calculating recoupments or penalties for audits. | | | 11| B. A recoupment of any disputed funds shall only occur after | | | 12|final internal disposition of the audit, including the appeals | | | 13|process as described in subsection C of this section. | | | 14| C. 1. An auditor that conducts an audit shall: | | | 15| a. establish an appeals process under which a health | | | 16| care provider may appeal an unfavorable preliminary | | | 17| audit report to the auditor, and | | | 18| b. provide a copy of the final audit report to the | | | 19| health benefit plan sponsor after the completion of | | | 20| any review process. | | | 21| 2. If following the appeal pursuant to subparagraph a of | | | 22|paragraph 1 of this subsection the auditor finds that an unfavorable | | | 23|audit report or any portion of the unfavorable audit report is | | | 24|unsubstantiated, the auditor shall dismiss the audit report or the | | | Req. No. 14797 Page 6 ___________________________________________________________________________
1|unsubstantiated portion of the audit report without any further | | | 2|proceedings. | | | 3| D. The total amount of any recoupment on an audit shall be | | | 4|refunded to the party responsible for payment of the claim. | | | 5| SECTION 4. This act shall become effective November 1, 2026. | | | 6| | | | 7| 60-2-14797 TJ 01/06/26 | | | 8| | | | 9| | | | 10| | | | 11| | | | 12| | | | 13| | | | 14| | | | 15| | | | 16| | | | 17| | | | 18| | | | 19| | | | 20| | | | 21| | | | 22| | | | 23| | | | 24| | | | Req. No. 14797 Page 7