Current through all regulations passed and filed through March 18, 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