Current through Register Vol. 51, No. 19, September 20, 2024
A. The
Department or its designee shall notify each provider participating in the
Program of the results of the final settlement under Regulation .11 of this
chapter.
B. Within 60 days after
the provider receives the notification described in §A of this regulation,
the Department shall pay the amount due to the provider regardless of whether
the provider files an appeal.
C.
The provider may request review of the settlement under Regulation .11 of this
chapter by filing written notice with the Program's Appeal Board within 30 days
after receipt of the notification of the results of the settlement from the
Department or its designee.
D. The
Appeal Board shall be composed of the following:
(1) A representative of the hospital industry
who is:
(a) Knowledgeable in Medicare and
Medicaid reimbursement principles; and
(b) Appointed by the Secretary of the
Department;
(2) A person
who:
(a) Is employed by the State;
(b) Is knowledgeable in Medicare and Medicaid
reimbursement principles;
(c) Did
not participate in the verification of costs; and
(d) Is appointed by the Secretary of the
Department; and
(3) A
third member selected by the first two members of the Appeal Board.
E. When the Appeal Board reviews
an appeal from a provider in which an Appeal Board member is employed or in
which the member has a financial or personal interest, the Secretary of the
Department shall designate an alternate for the member.
F. If the provider elects not to appeal to
the Appeal Board:
(1) The provider shall pay
the amount due within 60 days after the notification described in §A of
this regulation;
(2) If the
provider requests a longer payment schedule within 60 days after the provider
receives notification of the amount due the Program, the Department may
establish, after consultation with the provider, a longer payment schedule;
and
(3) The Department shall
establish a longer payment schedule if, in the Department's judgment based on
sufficient documentation submitted by the provider, failure to grant a longer
payment schedule would:
(a) Result in
financial hardship to the provider; or
(b) Have an adverse effect on the quality of
participant care furnished by the facility.
G. If the provider elects to appeal to the
Appeal Board, the following provisions apply:
(1) Within 30 days after a provider appeals a
determination by the Department or its designee that the provider owes money to
the Program, the Department or its designee shall:
(a) Recalculate the amount due to the Program
based on the verification, exclusive of the amount in controversy which is
subject to the appeal; and
(b)
Notify the provider of that amount;
(2) In order to enable the Department or its
designee to perform this recalculation, the provider shall indicate the
specific adjustment and the specific amount being appealed;
(3) Subject to the provisions of §G(4)
of this regulation, payment for the amount due the Program, if any, after the
recalculation, shall be made within 60 days after the provider receives
notification of the recalculation; and
(4) If a provider requests a longer payment
schedule within 60 days after the provider receives notification of the
recalculation, the Department may establish, after consultation with the
provider, a longer payment schedule in accordance with §F(3) of this
regulation.
H. Appeal
Board Findings.
(1) After the Department
receives the findings of the Appeal Board, the Department shall:
(a) Determine the amount that is due either
to the Program or to the provider; and
(b) Notify the provider of that
amount.
(2) The portion
of the amount in controversy that is paid is subject to an award of interest
that is:
(a) Calculated from the date the
appeal was filed through the date of payment; and
(b) Based on the 6-month Treasury Bill rate
in effect on the date the appeal was filed.
(3) Interest paid to a provider under
§H(2) of this regulation is not subject to any offset or other reduction
against otherwise allowable costs.
(4) If the provider accepted the
determination made under §H(1) of this regulation, within 60 days after
the provider receives the notification under §H(1) of this regulation, the
Program shall pay the amount the Department determined is due the provider, if
any.
(5) Subject to §H(6) of
this regulation, within 60 days after the provider receives the notification,
the provider shall pay the amount due the Program, if any.
(6) If a provider requests a longer payment
schedule within 30 days after the provider receives notification of the amount
due the Program, the Department may establish, after consultation with the
provider, a longer payment schedule in accordance with §F(3) of this
regulation.
I. After
expiration of the 60-day payment period, or longer payment schedule established
by the Department as described in §§F-H of this regulation, and in
addition to the sanctions provided in Regulation .14 of this chapter, the
Department may recover the unpaid balance by withholding the amount due from
the interim payment which would otherwise be payable to the provider.
J. The Department or a provider aggrieved by
a reimbursement decision of the Appeal Board may appeal the decision of the
Appeal Board as the final decision for judicial review under the Administrative
Procedure Act, State Government Article, §10-222, Annotated
Code of Maryland.
K. If the
provider or the Department appeals the final decision of the Appeal Board, the
provider or the Department shall place any money due from the provider or from
the Program in an interest-bearing escrow account. The money due shall include
the interest, based on the rate in §H(2)(b) of this regulation, calculated
from the date of the administrative appeal through the date of opening the
escrow account. The money shall remain in escrow until a final decision has
been rendered. Upon a final determination of the dispute, the appropriate
person administering the escrow account shall distribute the money in that
account, including any interest accrued, in conformity with the final
determination.
L. The provider may
file an appeal of the results of the settlement with the Medicare Appeal Board
as a substitute for the Department's Appeal Board, and the decision rendered by
the Medicare Appeal Board will be accepted by the Department as
binding.
