Committee backs sampling authority for pediatric behavioral therapy audits, adopts guardrails sought by providers

The Senate Appropriations Committee approved House Bill 14‑12 after adopting amendments designed to limit the reach of statistical sampling and extrapolation for recoupments in the pediatric behavioral therapy (PBT) Medicaid program.

Sponsor supporters said the authority is necessary to recover improper payments and strengthen program integrity after an Office of Inspector General review identified payment issues. Several provider organizations and legal advocates urged caution and requested explicit guardrails: require the Department of Health Care Policy & Financing to use OIG/HHS‑approved sampling methods, limit the look‑back period to years covered in the OIG review, and prohibit extrapolation based solely on documentation deficiencies where guidance was absent at the time of service.

Brian Davey of Action Behavior Centers and other providers said the OIG/HHS methodology is a well‑tested standard and that replicate use will help avoid unfair, large recoupments based on a small audited sample. Daniel Unum, representing COABA, and several providers urged that documentation lapses not automatically trigger extrapolated repayment when the underlying services were provided and preauthorization existed.

Committee members adopted amendment L002 (restoring OIG methodology references and other guardrails) and advanced the bill unanimously; members discussed appeal processes for providers and a likely need for additional implementation guidance.

Sponsor and JBC staff said the department must balance program integrity with access, and the amendment aims to provide clearer standards for both auditors and providers.