Hospital Audits

RCNY tit. 44, ch. 4

in effect

44 RCNY § 4-01 Final Audit Report.

§ 4-01 Final Audit Report. (a) After the receipt of the hospital's objections to the draft audit report, or if no objections have been received within 30 days after mailing the draft audit report to the hospital, a final report shall be issued. In preparing the final audit report, the Bureau of Financial Audit (BFA) of the New York City Comptroller's Office (Comptroller) shall consider the objections, any supporting documents and materials submitted therewith, the draft audit report, and any additional material which may become available. (b) The final audit report and/or the cover letter accompanying it shall clearly advise the hospital: (1) of the nature and amount of the audit findings, the basis for the action and the statutory, regulatory or other legal basis therefore; (2) of the action which will be taken; (3) that the withholding action will occur 35 days from the date of the final audit report unless an appeal is taken; (4) of the right to appeal the administrative action by requesting a hearing; (5) the name, title, address and telephone number of the BFA's Director whom the hospital must contact to request a hearing; (6) that a request for a hearing must be made in writing and postmarked or delivered within 30 days of receipt of the final audit report which shall be presumed to be five days from the date of mailing; and (7) that the request may not address issues regarding the: (i) statistical sampling and extrapolation methodologies used to determine the disallowances; (ii) disallowances where patient account records to substantiate billings were missing at the time of the audit; or (iii) any issue that could have been raised, but was not, in a written response to the draft report. (Renumbered City Record 6/29/2018, eff. 7/29/2018)

44 RCNY § 4-02 Request for Hearing.

§ 4-02 Request for Hearing. (a) A hospital has the right to an administrative hearing to challenge the final audit report and may request such a hearing within 30 days of receipt of the final audit report which shall be presumed to be five days from the date of mailing. (b) The request for hearing shall be in writing and shall be delivered or mailed to the BFA's Director, who will forward such request to the New York City Office of Administrative Trials and Hearings (OATH) for scheduling on the calendar. It shall be accompanied by a copy of the final audit report which is to be the subject of the hearing and shall include the following additional information: (1) the specific item or items to which objections are made; (2) the factual basis for the objections; and (3) any legal authority for the objections. (c) When a timely request for a hearing has been made, a hearing shall be held, except when the request has been withdrawn or abandoned by the hospital. (1) A request for a hearing shall be considered withdrawn only upon receipt of a written statement or by the making of a statement on the record at the hearing by the hospital or by the hospital's attorney or representative. (2) A request for a hearing shall be considered abandoned if, without good cause, neither the hospital nor the hospital's attorney or representative appears at the time and place designated for the hearing. (d) Upon receipt of a request for a hearing, the BFA's Director shall: (1) have OATH designate an Administrative Law Judge to hear, report and recommend; and establish a time and place for such hearing; (2) notify the hospital of the time and place of such hearing at least 15 days before the commencement of the hearing; (3) include in a notice of hearing a statement: (i) of those issues which are controverted and to be determined at the hearing; (ii) of the legal authority and jurisdiction under which the hearing is to be held, and a reference to the particular sections of the law and rules involved; (iii) of the hospital's right to be represented by an attorney or other representative, to cross-examination, to present evidence and produce witnesses on the hospital's own behalf; and (iv) that the burden of proof at the hearing shall be on the hospital. (Renumbered City Record 6/29/2018, eff. 7/29/2018)

44 RCNY § 4-03 The Hearing Officer.

§ 4-03 The Hearing Officer. The hearing shall be conducted by an Administrative Law Judge employed by OATH for that purpose. The judge shall have all the powers conferred by law to administer oaths, issue subpoenas, require the attendance of witnesses and production of records, rule upon requests for adjournment, rule upon evidentiary matters and to otherwise regulate the hearing, observe requirements of due process and effectuate the purposes and provisions of applicable law. (Renumbered City Record 6/29/2018, eff. 7/29/2018)

44 RCNY § 4-04 Authorization of Representative.

§ 4-04 Authorization of Representative. An individual, other than an attorney, representing the hospital, shall have written authorization signed by an officer or director of the hospital. (Renumbered City Record 6/29/2018, eff. 7/29/2018)

44 RCNY § 4-05 Conduct of Hearings; Rights of Hospital.

§ 4-05 Conduct of Hearings; Rights of Hospital. (a) The judge shall preside over the hearing, make all procedural rulings, and make a statement on the record describing the nature of the proceedings, the issues, and the manner in which the hearing will be conducted. (b) The issues and documentation presented at the hearing shall be limited to issues relating to determinations made in the final audit report. A hospital may not raise issues regarding the: (1) statistical sampling and extrapolation methodologies used to determine the disallowances; (2) disallowances where patient account records to substantiate billings were missing at the time of the audit; or (3) any issue that could have been raised, but was not, in a written response to the draft report. (c) The rules of evidence observed by a court of law need not apply. (d) Computer-generated documents prepared by the New York State Department of Social Services (NYSDSS) or its fiscal agent to show the nature and amount of payments made under the Medicaid program shall be presumed, in the absence of evidence to the contrary, to constitute an accurate reflection of NYSDSS' records as to the amount and type of payment made to a hospital as well as the basis for such payment. (e) An extrapolation based upon a Comptroller's Office audit utilizing a valid statistical sampling method shall be presumed, in the absence of evidence to the contrary, to be accurate. (f) An audit report of the Comptroller's Office shall be presumed to be correct and the burden of proof shall be upon the hospital to show by a preponderance of the evidence that any item of such report is incorrect. (g) All testimony shall be given under oath or affirmation administered by the judge. (h) The hospital shall be entitled to be represented, to have witnesses give testimony and to otherwise present relevant and material evidence on the hospital's behalf, to cross-examine witnesses and to examine any document or other item offered into evidence. (i) A typed or recorded copy of the record of the hearing will be prepared by OATH; a copy shall be provided upon request for a reasonable cost. (j) At the discretion of the judge, the hearing may be adjourned for good cause upon the request of either party or upon the judge's own motion. (k) The hearing shall be conducted in conformity with procedural requirements of applicable law and the rules of procedure adopted by OATH which are not inconsistent with these rules. (l) After the conclusion of the hearing, the presiding Administrative Law Judge will prepare a report and recommendation. (m) The report will summarize the evidence presented and contain an analysis of the legal and factual issues, with recommended findings of fact and recommended dis- position. (n) The report will be sent to the Comptroller for a final decision. (o) A copy of the report will also be delivered or mailed to the hospital. (Renumbered City Record 6/29/2018, eff. 7/29/2018)

44 RCNY § 4-06 Decision After Hearing.

§ 4-06 Decision After Hearing. (a) The hearing decision shall be made and issued by the Comptroller and shall be based exclusively on the record and transcript of the hearing. In reaching a decision, the Comptroller may review the memoranda of law of the parties, if any. The Comptroller shall not be bound by the judge's recommendation but may adopt, reject or modify such recommendation, in whole or in part, as may be appropriate. The decision shall be in writing and shall state reasons for the determinations and, when appropriate, direct specific action. (b) A copy of such decision shall be mailed by the Comptroller to the hospital and the hospital's attorney or representative, if any, and to NYSDSS. (c) In the event that a decision is adverse to the hospital, in whole or in part, the hospital has the right to judicial review in accordance with the provisions of Article 78 of the Civil Practice Law and Rules. (Renumbered City Record 6/29/2018, eff. 7/29/2018)

44 RCNY § 4-07 Recoupment of Overpayments.

§ 4-07 Recoupment of Overpayments. Upon determination that overpayments have been made, the BFA shall transmit a "Withholding Request for Provider Recoupment Initiated by the Local District" to NYSDSS. NYSDSS' fiscal agent shall recover overpayments by withholding against the hospital's current or future payments on claims submitted or a percentage of payments otherwise payable on such claims, at the option of NYSDSS. Such withholding may be made at any time after the issuance of a decision after hearing or, if a hearing has not been requested in accordance with this chapter, at any time after expiration of the time period allowed (30 days) for the making of such request. (Renumbered City Record 6/29/2018, eff. 7/29/2018)

Source: City of New York, Charter, Administrative Code and Rules (American Legal Publishing XML export, codelibrary.amlegal.com)URL: https://codelibrary.amlegal.com/codes/newyorkcity/latest/NYCrules/0-0-0-82837Fetched: 10/24/2026