Current through Register Vol. 50, No. 9, September 20, 2024
A. Any hospital seeking an adjustment to its
rate, shall submit a written request for administrative review to the Medicaid
director (hereafter referred to as director) within 30 days after receipt of
the letter notifying the hospital of its rates.
1. The receipt of the letter notifying the
hospital of its rates shall be deemed to be five days from the date of the
letter.
2. The time period for
requesting an administrative review may be extended upon written agreement
between the department and the hospital.
B. The department will acknowledge receipt of
the written request within 30 days after actual receipt. Additional
documentation may be requested from the hospital as may be necessary for the
director to render a decision. The director shall issue a written decision upon
the hospital's request for a rate adjustment within 90 days after receipt of
all additional documentation or information requested.
C. Any hospital seeking an adjustment to its
rate, must specify all of the following:
1.
the nature of the adjustment sought;
2. the amount of the adjustment sought;
and
3. the reasons or factors that
the hospital believes justify an adjustment.
D. Any request for an adjustment must include
an analysis demonstrating the extent to which the hospital is incurring or
expects to incur a qualifying loss in providing covered services to Medicaid
and indigent patients.
1. For purposes of
these provisions, qualifying loss shall mean that amount by which the
hospital's allowable costs (excluding disproportionate share payment
adjustments) exceed the Medicaid reimbursement implemented pursuant to these
provisions.
2. "Cost" when used in
the context of allowable shall mean a hospital's costs incurred in providing
covered inpatient services to Medicaid and indigent patients, as calculated in
the relevant definitions governing cost reporting.
E. The hospital will not be required to
present an analysis of its qualifying loss where the basis for its appeal is
limited to a claim that:
1. the rate-setting
methodology or criteria for classifying hospitals or hospital claims under the
state plan were incorrectly applied;
2. that incorrect or incomplete data or
erroneous calculations were used in establishment of the hospital rates;
or
3. the hospital had incurred
additional costs because of a catastrophe that meets certain
conditions.
F. Except in
cases where the basis for the hospital's appeal is limited to a claim that
rate-setting methodologies or principles of reimbursement established under the
reimbursement plan were incorrectly applied, or that the incorrect or
incomplete data or erroneous calculations were in the establishment of the
hospital's rate, the department will not award additional reimbursement to a
hospital, unless the hospital demonstrates that the reimbursement it receives
based on its prospective rate is 70 percent or less of the allowable costs it
incurs in providing Medicaid patients care and services that conform to the
applicable state and federal laws of quality and safety standards.
1. The department will not increase a
provider's rate to more than 105 percent of the peer group rate.
G. In cases where the rate appeal
relates to an unresolved dispute between the hospital and its Medicare fiscal
intermediary as to any cost reported in the hospital's base year cost report,
the director will resolve such disputes for purposes of deciding the request
for administrative review.
H. The
following matters will not be subject to appeal:
1. the use of peer grouped rates;
2. the use of teaching, non-teaching and
bed-size as criteria for hospital peer groups;
3. the use of approved graduate medical
education and intern and resident full time equivalents as criteria for major
teaching status;
4. the use of
fiscal year 1991 medical education costs to establish a hospital-specific
medical education component of each teaching hospital's prospective
rate;
5. the application of
inflationary adjustments contingent on funding appropriated by the
legislature;
6. the criteria used
to establish the levels of neonatal intensive care;
7. the criteria used to establish the levels
of pediatric intensive care;
8. the
methodology used to calculate the boarder baby rates for nursery;
9. the use of hospital specific costs for
transplant per diem limits;
10. the
criteria used to identify specialty hospital peer groups; and
11. the criteria used to establish the level
of burn care.
I. The
hospital shall bear the burden of proof in establishing facts and circumstances
necessary to support a rate adjustment. Any costs that the provider cites as a
basis for relief under this provision must be calculable and
auditable.
J. The department may
award additional reimbursement to a hospital that demonstrates by clear and
convincing evidence that:
1. a qualifying
loss has occurred and the hospitals current prospective rate jeopardized the
hospital's long-term financial viability; and
2. the Medicaid population served by the
hospital has no reasonable access to other inpatient hospitals for the services
that the hospital provides and that the hospital contends are under reimbursed;
or
3. alternatively, demonstrates
that its uninsured care hospital costs exceeds 5 percent of its total hospital
costs, and a minimum of $9,000,000 in uninsured care hospital cost in the
preceding 12 month time period and the hospital's uninsured care costs has
increased at least 35 percent during a consecutive six month time period during
the hospital's latest cost reporting period.
a. For purposes of these provisions, an
uninsured patient is defined as a patient that is not eligible for Medicare or
Medicaid and does not have insurance.
b. For purposes of these provisions,
uninsured care costs are defined as uninsured care charges multiplied by the
cost to charge ratios by revenue code per the last filed cost report, net of
payments received from uninsured patients.
i.
The increase in uninsured care costs must be a direct result of a permanent or
long term (no less than six months) documented change in services that occurred
at a state owned and operated hospital located less than eight miles from the
impacted hospital.
ii. For the
purpose of this Rule, if a hospital has multiple locations of service, each
location shall measure uninsured care costs separately and qualify each
location as an individual hospital. Rate adjustments awarded under this
provision will be determined by the secretary of the department and shall not
exceed 5 percent of the applicable per diem rate.
K. In determining
whether to award additional reimbursement to a hospital that has made the
showing required, the director shall consider one or more of the following
factors and may take any of these actions.
1.
The director shall consider whether the hospital has demonstrated that its
unreimbursed costs are generated by factors generally not shared by other
hospitals in the hospital's peer group. Such factors may include, but are not
limited to extraordinary circumstances beyond the control of the hospital and
improvements required to comply with licensing or accrediting standards. Where
it appears from the evidence presented that the hospital's costs are
controllable through good management practices or cost containment measures or
that the hospital has through advertisement to the general public promoted the
use of high costs services that could be provided in a more cost effective
manner, the director may deny the request for rate adjustment.
2. The director may consider, and may require
the hospital to provide financial data, including but not limited to financial
ratio data indicative of the hospital's performance quality in particular areas
of hospital operation.
3. The
director shall consider whether the hospital has taken every reasonable action
to contain costs on a hospital-wide basis. In making such a determination, the
director may require the hospital to provide audited cost data or other
quantitative data including, but not limited to:
a. occupancy statistics;
b. average hourly wages paid;
c. nursing salaries per adjusted patient
day;
d. average length of
stay;
e. cost per ancillary
procedure;
f. average cost per meal
served;
g. average cost per pound
of laundry;
h. average cost per
pharmacy prescription;
i.
housekeeping costs per square foot;
j. medical records costs per
admission;
k. full-time equivalent
employees per occupied bed;
l. age
of receivables;
m. bad debt
percentage;
n. inventory turnover
rate; and
o. information about
actions that the hospital has taken to contain costs.
4. The director may also require that an
onsite operational review/audit of the hospital be conducted by the department
or its designee.
L. In
awarding relief under this provision, the director shall:
1. make any necessary adjustments so as to
correctly apply the rate-setting methodology, to the hospital submitting the
appeal, or to correct calculations, data errors or omissions; or
2. increase one or more of the hospital's
rates by an amount that can reasonably be expected to ensure continuing access
to sufficient inpatient hospital services of adequate quality for Medicaid
patients served by the hospital.
M. The following decisions by the director
shall not result in any change in the peer group rates:
1. the decision to:
a. recognize omitted, additional or increased
costs incurred by any hospital;
b.
adjust the hospital rates; or
c.
otherwise award additional reimbursement to any hospital.
N. Hospitals that qualify under
this provision must document their continuing eligibility at the beginning of
each subsequent state fiscal year. Rate adjustments granted under this
provision shall be effective from the first day of the rate period to which the
hospital's appeal relates. However, no retroactive adjustments will be made to
the rate or rates that were paid during any prior rate period.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
