Current through all regulations passed and filed through September 16, 2024
(A) The definitions
of all terms not defined in this rule are the same as set forth in rules
5160-3-01 and 5160-3- 43.1 of the Administrative
Code.
(1) "Combination review" is a type of
exception review where the Ohio department of medicaid
(ODM) reviews records selected in one of the following ways:
(a) A combination of records selected
pursuant to random and targeted criteria.
(b) Records initially selected for a targeted
review, but insufficient records were available to meet the targeted review
sample size requirements, combined with
randomly selected records to complete the sample size.
(c) Records initially selected for a random
review, combined with records selected for a
targeted review as a result of findings of the random review.
(2)
"Effective date of the rate" is either the first day of July or January for a
given fiscal year.
(3) "Exception review"
is a review of minimum data set (MDS) assessment data. It is conducted at
selected NFs by registered nurses and other appropriate
licensed or certified health professionals as
determined by ODM who are employed by or under contract with
ODM.
The purpose of an exception review is to identify any
patterns or trends related to resident assessments submitted in accordance with
rule 5160-3- 43.1 of the Administrative Codethat could
result in inaccurate case mix scores used to calculate the direct care
component of the nursing facility per diem rate.
Exception reviews shall be conducted in accordance with
section 5165.193 of the Revised
Code.
(4)
"Exception review tolerance level" is the level of variance between the
facility and ODM in MDS assessment item responses affecting the
resource utilization groups
(RUG ) classification of a facility's
residents. Two kinds of tolerance levels have been established for exception
reviews: initial sample tolerance level, and expanded review tolerance level.
(a) "Initial sample tolerance level" is the
percentage of unverifiable records found during the initial sample of an
exception review, below which no further review will be pursued for the same
six month period. The initial sample tolerance level shall be less than fifteen
per cent of the entire sample.
(b)
"Expanded review tolerance level" is an acceptable level of variance in the
calculation of a provider's quarterly facility average medicaid case mix score
or an acceptable per cent of the records sampled at exception review that were
unverifiable.
(5)
"Random review" is a type of exception review that examines randomly selected
records from any of the RUG major
categories listed in paragraph (C) of
rule 5160-3-43.2 of the
Administrative Code.
(6)
"Targeted review" is a type of exception review that targets records in
restorative nursing programs, current toileting program or trial, and/or bowel
toileting program, clinically complex with depression, or one or more of the RUG major
categories listed in paragraph (C) of rule 5160-3-43,2
of the Administrative Code
.
(7) The "variance" is
the percentage difference between the quarterly facility average medicaid case
mix score based on exception review findings and the quarterly facility average
medicaid case mix score from the provider's submitted MDS records.
(a) The exception review tolerance level
shall be either less than a two per cent variance between the quarterly
facility average medicaid case mix score based on exception review findings and
the quarterly facility average medicaid case mix score from the provider's
submitted MDS records or less than twenty per cent of the medicaid records
sampled at exception review were unverifiable.
(b) The variance calculation will not
recognize modifications to MDS assessments and new assessments following an
inactivation, submitted by the facility after notification of the exception
review.
(8) A "verifiable MDS
record" is a provider's completed MDS assessment form, based on facility
supplied MDS assessment data submitted to
ODM
for a resident for a specific reporting quarter, which upon examination
by ODM
during an exception review has been
determined to accurately represent the aspects of the resident's
condition
that
affect the correct RUG classification of that record during the specified
assessment time frame.
(9) An "unverifiable
MDS record" is a provider's completed MDS assessment form, based on facility
supplied MDS assessment data, submitted to ODM for a resident for a specific
reporting quarter which, upon examination by ODM, has been
determined to inaccurately represent the aspects of the resident's
condition
that
affect the RUG classification of that record during the specified
assessment time frame. MDS coding may be deemed unsupported if
inconsistencies are found in the sources of information through verification
activities.
(B) All
exception reviews will comply with the applicable provisions of the medicare
and medicaid programs.
(C)
Providers may be selected for an exception review by
ODM based on
any of the following:
(1) The findings of a
certification survey conducted by the Ohio department of health
(ODH) that may indicate that the facility is not
accurately assessing residents, which may result in the resident's inaccurate
classification into the RUG
system.
(2) A
risk analysis profile that may include, but is not limited to, one or more of
the following:
(a) A change in the frequency
distribution of residents
who receive nursing rehabilitation/restorative care
in accordance with section O of the minimum data set
version 3.0 (MDS 3.0), or who meet the RUG
criteria fordepression
in accordance with section D of the MDS
3.0.
(b) The frequency
distribution of residents who receive nursing
rehabilitation/restorative care in accordance with
section O of the MDS 3.0, or who meet the RUG
criteria for
depression in accordance with section D of the MDS
3.0
exceeds statewide
averages.
(c) A
sudden or drastic change in the quarterly
facility average total case mix score
or the quarterly facility average medicaid case mix
score.
(d) A
change in the frequency distribution of coded responses to a MDS
item.
(3) Prior resident
assessment performance of the provider, may include, but is not limited to, ongoing problems with
assessment submission deadlines, error rates, incorrect assessment dates, and
apparent unchanged assessment practice(s) following a previous exception
review.
(D) Exception
reviews shall be conducted at the facility by registered nurses and other
licensed or certified health professionals as
determined by ODM who are under contract with or employed by
ODM.
When a team of reviewers conducts an
on-site exception review, the team shall be led by a registered nurse. Persons
conducting exception reviews on behalf of ODM shall meet
the following conditions:
(1) During the
period of their professional employment or
contract with ODM, whichever is applicable, reviewers must neither
have nor be committed to acquire any direct or indirect financial interest in
the ownership, financing, or operation of a NF for which they conduct an
exception review .
Employment of a member of a reviewer's family by a
provider at which the reviewer does not conduct an exception review does not
constitute a direct or indirect financial interest in the ownership, financing,
or operation of the provider on the part of the reviewer.
(2) Reviewers shall not
conduct an exception review
at any
facility
where a member of their family is a current resident.
(3) Reviewers shall not
conduct an exception review
at any
facility
that has been a client of the reviewer within the past twenty-four months.
(4)
Reviewers shall not conduct an exception review
at any
facility
that has been an employer of the reviewer within the past twenty-four
months.
(E) Prior
notice:
ODM shall notify the provider by telephone at least
two working days prior to the review.
(F) Providers selected for exception reviews
must provide reviewers with
reasonable access to residents, professional and nonlicensed direct care staff,
the facility assessors, and completed resident assessment instruments and
supporting documentation regarding the residents' care needs and treatments.
Providers must also provide
ODM with sufficient information to be able to
contact the resident's attending or consulting physicians, other professionals
from all disciplines who have observed, evaluated, or treated the resident, such as contracted
therapists, and the resident's family
or significant others. These sources of
information may help to validate information provided on the resident
assessment instrument submitted to ODM. Verification activities may
include reviewing resident assessment forms and supporting documentation,
conducting interviews with staff knowledgeable about the resident during the
observation period for the MDS, and observing residents.
(G) An exception review shall be conducted of
a random, targeted, or a combination of random and targeted samples of
completed resident assessment instruments. The initial sample size shall be
greater than or equal to the minimum sample size . The expanded
sample size is based on the initial sample
findings. Sample sizes are
available on the ODM website at http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTermCareFacilities.aspx.
(H) Results from review of the initial sample
shall be used to decide if further action by
ODM is
warranted. If the initial sample is to be expanded for further review,
ODM
reviewers shall hold a conference with facility representatives advising them
of the next steps of the review and discussing the initial sample findings. If
the sample of reviewed records exceeds the initial sample tolerance level
described in paragraph (A)(4)(a) of this rule, ODM may subsequently
expand the exception review process as follows:
(1)
If the initial
sample was a targeted review, the expanded sample size shall be the lesser of
the remaining records in the targeted category or the applicable minimum
expanded sample size.
(2)
If the initial sample was a random review that became
a targeted review, the expanded sample shall be the lesser of the remaining
records in the targeted category or the applicable minimum expanded sample
size.
(3)
If the initial sample was a random review, the
expanded sample size shall be at least the applicable minimum sample
size.
(4)
If the initial sample was a combination review, the
expanded sample size shall be at least the applicable minimum sample size. The
expanded sample may consist of the remaining records in the targeted and random
categories.
(5)
If the expanded review tolerance level is exceeded,
ODM may subsequently expand the sample size for the same reporting quarter up
to and including one hundred per cent of the records and continue the review
process.
(I) At
the conclusion of the on-site portion of the exception review process,
reviewers shall hold an exit
conference with facility representatives. Reviewers will share preliminary
findings and/or concerns about verification or failure to verify RUG
classification for reviewed records.
Reviewers will give provider representatives one written preliminary copy of
the exception review findings indicating whether the facility was under or over
the established tolerance levels.
(J) All exception reviews shall include a
final written summary of the exception review findings, including the final facility tolerance level
calculations as
well as the revised quarterly facility average total case mix score and
the revised quarterly facility average medicaid
case mix score.
ODM shall mail a copy of the final written
summary to the provider.
(K) All
exception review reports shall be retained by
ODM for at
least six years.
(L) If the
expanded review tolerance level is exceeded,
ODM shall use
the exception review findings to calculate or recalculate resident case mix
scores, quarterly facility average total case mix
scores, quarterly and semiannual
facility average medicaid case mix scores, and
annual facility average case mix scores. Calculations or recalculations shall
apply only to records actually reviewed by
ODM and shall
not be based on extrapolations to unreviewed records of findings from reviewed
records. For example,
ODM shall recalculate the
quarterly facility average total case mix
score and
quarterly facility average medicaid case mix score by replacing resident
case mix scores of reviewed records and not changing the resident case mix
scores of unreviewed records.
(M)
ODM
shall use the quarterly facility average total case mix
score, quarterly and semiannual
facility average medicaid case mix scores, and
annual facility average case mix
score based on exception review findings
that
exceed the exception review tolerance level to calculate or recalculate
the facility's rate for direct care costs for the appropriate six month
period(s). However, scores recalculated based on exception review findings
shall not be used to override any assignment of a quarterly facility average
total case mix score,
quarterly facility average medicaid case mix score, or a peer group cost
per case mix unit made in accordance with rule 5160-3-
43.3 of the Administrative Code as a result of the facility's failure to
submit, or submission of incomplete or inaccurate resident assessment
information, unless the recalculation results in a lower quarterly
facility average total case mix score, or
lower quarterly or semiannual facility average
medicaid case mix score, or lower peer group
cost per case mix unit than the one to be assigned.
(1) If the exception review of a specific
reporting quarter is conducted before the effective date of the rate for the
corresponding six month period, and the review results in findings that exceed
the tolerance level,
ODM shall use the recalculated quarterly facility
average total case mix
score and quarterly
facility average medicaid case mix score to calculate the facility's
semiannual facility average
medicaid case mix score for the facility's direct
care rate for that six month period. Calculated rates based on exception review
findings may result in a rate increase or rate decrease compared to the rate
based on the facility's submission of assessment information.
(2) If the exception review of a specific
reporting quarter is conducted after the effective date of the rate for a
corresponding six month period, and the review results in findings that exceed
the exception review tolerance level and indicate the facility received a lower
rate than it was entitled to receive,
ODM shall increase the direct care rate
prospectively for the remainder of the six month period, beginning one month
after the first day of the month after the exception review is
completed.
(3) If the exception
review of a specific reporting quarter is conducted after the effective date of
the rate for a corresponding six month period, and the review results in
findings that exceed the exception review tolerance level and indicate the
facility received a higher rate than it was entitled to receive,
ODM
shall reduce the direct care rate and apply it to the six month periods when
the provider received the incorrect rate to determine the amount of the
overpayment. Overpayments are payable in accordance with rule
5160-3-22 of the Administrative Code.
(N) Except for additional
information submitted to
ODM as part of the processes set forth in
paragraphs (O) and (P) of this rule, the
ODM exception
review determination for any resident case mix score shall be considered final.
A provider may submit corrections for individual records in accordance with
rule 5160-3- 43.1 of the Administrative Code; however, the
exception review determination for any resident assessment case mix score will
be used to establish the quarterly facility
average total case mix score, quarterly and semiannual facility average medicaid case
mix scores, and annual facility average case mix score.
(O)
A provider may seek reconsideration of any
prospective direct care rate that was established by recalculating the direct care
rate as a result of an exception review of resident assessment information
conducted before the effective date of the rate.
(1) A reconsideration of
a prospective direct care rate on the basis of a dispute with
ODM
exception review findings shall be submitted by the
provider to
ODM in accordance with the following:
(a)
The request shall be submitted no later than thirty
days after receipt of the exception review finding.
(b)
The request
shall be in writing, and shall be addressed to "Ohio Department of Medicaid,
Bureau of Long Term Care Services and Supports, P.O. Box 182709, 5th Floor,
Columbus, Ohio, 43218".
(c)
The request shall indicate that it is a request for
rate reconsideration due to a dispute with exception review
findings.
(d)
The request shall include a detailed explanation of
the items on the resident assessment records under dispute as well as copies of
relevant supporting documentation from specific individual records. The request
shall also include the provider's proposed resolution.
(2)
ODM
shall respond in writing within sixty days of receiving each written request
for a rate reconsideration related to disputed exception review findings. If
ODM
requests additional information to determine if the rate adjustment is
warranted, the provider shall respond in writing and shall provide additional
supporting documentation no more than thirty days after the receipt of the
request for additional information.
ODM shall respond in writing within sixty days of
receiving the additional information .
(3) If the rate is
increased pursuant to a rate reconsideration due to disputed exception review
findings, the rate adjustment shall be implemented retroactively to the initial
service date for which the rate is effective.
(4) When calculating
the annual facility average and semiannual
facility average medicaid case mix scores in
accordance with rule 5160-3- 43.3of the Administrative Code,
ODM
shall use any resident case mix scores adjusted as a result of a rate
reconsideration determination in lieu of the resident case mix scores from the
exception review findings.
(P) The findings of an exception review
conducted after the effective date of the rate may be appealed under
Chapter 119. of the Revised Code.
ODM shall not
withhold from the facility's current payments any amounts
ODM
claims to be due from the facility as a result of the exception review findings
while the provider is pursuing administrative or judicial remedies in good
faith.
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