Current through all regulations passed and filed through September 16, 2024
(A)
The Ohio
department of medicaid (ODM) will perform or contract with a medical review
entity to perform utilization review for medicaid inpatient services regardless
of the payment methodology used for reimbursement of those services. For the
purposes of this rule, "ODM" means ODM or its contracted medical review entity.
During the course of its analyses, ODM may request information or records from
the hospital and may conduct on-site medical record reviews.
(B)
ODM will review a
statistical sample of all admissions retrospectively.
(1)
While the nature
of the review will vary depending on the category of admission, all admissions
selected will be reviewed to determine whether care was medically necessary on
an inpatient hospital basis; to determine if the care was medically necessary
as defined in rule
5160-1-01 of the Administrative
Code; to determine whether the discharge occurred at a medically appropriate
time; to assess the quality of care rendered as mandated in
42 C.F.R.
456.3(b), in effect as of
October 1, 2021; and to assess compliance with agency 5160 of the
Administrative Code.
(2)
If any of the cases reviewed for a hospital do not meet
the conditions described in paragraph (B)(1) of this rule, then ODM may deny
payment or recoup payment beginning with the first inappropriate admission or
discharge. Any negative determinations should be made by a
physician.
(3)
If the diagnostic or procedural information on the
claim is found to be inconsistent with that found in the medical records in
conjunction with the physician attestation, then changes may be made in the
coding and payment may be adjusted as described in paragraph (D)(3) of this
rule.
(4)
ODM may determine upon retrospective review, in
accordance with this rule, that the location of services was not medically
necessary, but that the services rendered were medically necessary. In such
instances:
(a)
The hospital may bill the department on an outpatient basis
for those medically necessary services that were rendered on the date of
admission in accordance with rule
5160-2-75 of the Administrative
Code.
(b)
Only laboratory and diagnostic radiology services
rendered during the remainder of the medically unnecessary admission may be
billed in accordance with rule
5160-2-75 of the Administrative
Code.
(c)
The outpatient bill will be submitted with a copy of
the reconsideration affirming the original decision or the administrative
decision issued in accordance with rule
5160-2-12 of the Administrative
Code.
(d)
The outpatient bill with attachments will be submitted
to the department within sixty calendar days from the date on the remittance
advice recouping the DRG payment for the medically unnecessary
admission.
(C)
ODM may include
in its retrospective review sample the categories of admissions described in
paragraphs (C)(1) to (D)(3) of this rule.
(1)
ODM may review
transfers as defined in rule
5160-2-02 of the Administrative
Code. The purpose of the transfer review will be to examine the documented
reasons for and appropriateness of the transfer. ODM considers a transfer
appropriate if the transfer is necessary because the individual needs some
treatment or care that is unavailable at the transferring hospital or if there
are other exceptional circumstances that justify transfer.
Cases will be individually considered
by ODM based on the merits of each case. If any of the hospital's transfer
cases reviewed are found to be inappropriate transfers, then ODM may intensify
the review, including the addition of prepayment review and pretransfer
certification. ODM may deny payment to or recoup payment from a provider who
has transferred patients inappropriately.
(2)
ODM may review
readmissions to determine if the readmission as defined in rule
5160-2-02 of the Administrative
Code is appropriate.
(a)
If the readmission is related to the first
hospitalization, ODM will determine if the readmission resulted from
complications or other circumstances that arose because of an early discharge
or other treatment errors.
(b)
If the
readmission is unrelated, ODM will determine if the treatment or care provided
during the readmission should have been provided during the first
hospitalization.
(c)
If it is determined the readmission was the result of
circumstances as described in paragraph (C)(2)(a) or (C)(2)(b) of this rule,
then any payment made for the separate admissions will be recouped. A new
payment amount will be determined by collapsing any affected admissions into
one payment.
(3)
ODM may review claims for which outlier payments are
made to determine if days or services were covered and were medically
necessary. For outliers, review will be made to determine that all services
were medically necessary, appropriately billed based on services rendered,
ordered by a practitioner of physician services and not duplicatively billed.
If it is determined that services were inappropriately billed or if days or
services are determined to be noncovered or not medically necessary as
described in rules
5160-1-01 and
5160-2-03 of the Administrative
Code, recoupment of any overpayments will occur. Overpayments will be
determined by calculating the difference between the amount paid and the amount
that would be paid if the nonallowable or noncovered days or services were
excluded from the claim.
(4)
ODM may review admissions with short lengths of stay.
Reviews in this category will be concentrated on any admission with a length of
stay greater than two standard deviations below the mean length of stay for the
DRG (diagnosis related groups) of that admission. This is based on the
distribution, by DRG, of lengths of stay of admissions in Ohio medicaid
inpatient claims. Reviews will be conducted to determine if the inpatient stay
was medically necessary to provide services or if the services rendered could
have been provided in an outpatient setting using observation codes as
described in rule
5160-2-75 of the Administrative
Code.
(5)
ODM may review cases in which a denial letter has been
issued by the hospital. In addition, ODM will review all cases in which the the
attending practitioner of physician services or recipient (or family member)
disagrees with the hospital's decision and requests a review of the case. The
hospital will send a copy of each denial letter to ODM's medical review
entity.
(D)
ODM may review medical records to validate DRG
assignment for any admission.
(1)
The physician attestation process is to be completed
for the medicaid program by following the medicare procedure for attestation as
delineated in
42 C.F.R.
412.46, in effect as of October 1,
2021.
(2)
DRG validation will be done on the basis of a review of
medical records by verifying that the diagnostic and procedural coding used by
the hospital is substantiated in these records.
(3)
If the diagnostic
and procedural information on the claim form is found to be inconsistent with
that found in the medical records in conjunction with the physician
attestation, the provider will submit a corrected claim reflecting this
information.
(E)
Pre-certification review as detailed in rule
5160-2-40 of the Administrative
Code will be conducted in addition to the utilization review activities
described in this rule.
(F)
Outpatient hospital services may also be reviewed by
ODM to determine whether the care or services were medically necessary as
defined in rule
5160-1-01 of the Administrative
Code, to determine whether the services were appropriately billed, and to
assess the quality of care rendered as mandated in
42 C.F.R.
456.3(b), in effect as of
October 1, 2021.
(G)
Intensified reviews may result whenever ODM identifies
inappropriate admission or billing practices during reviews conducted in
accordance with this rule. These reviews may periodically necessitate that
hospitals produce evidence of invoice costs supporting amounts billed for
take-home drugs.
(H)
Medical records will be maintained in accordance with
42 C.F.R.
482.24, in effect as of October 1, 2021.
Records requested by ODM for review will be supplied within thirty calendar
days of the request as described in rule
5160-1-17.2 of the
Administrative Code. Failure to produce records within thirty days will result
in withholding or recoupment of medicaid payments.
(I)
With the
exception of paragraph (H) of this rule, decisions made by ODM as described in
this rule are appealable to ODM and are subject to the reconsideration process
described in rule
5160-2-12 of the Administrative
Code.
(J)
Over or under payments resulting from a utilization
review will be settled in accordance with section
5164.57 of the Revised
Code.
(K)
Recovery of payments for professional services.
Payments made in accordance with
appendix DD to rule
5160-1-60 of the Administrative
Code for professional services that are associated with a recouped hospital
payment that is not eligible for resubmission due to the results of a
utilization review, will be recovered by ODM.
Replaces: 5160-2- 07.13
