Current through September 21, 2024
(a)
Request for TEFRA target rate adjustment. A provider may request a rate
adjustment by mailing a written request to the Department by certified mail
within sixty days after the date of the Notice of Medicaid Program
Reimbursement provided pursuant to subsection 8(c). The request must include
the information included in subparagraphs (i) through (iii). A request for rate
adjustment shall be dismissed with : this subsection.not comply with the
requirements of this subsection.
(i) The
nature of the rate adjustment sought;
(ii) The amount of the requested rate
adjustment, the methodology used to calculate the requested rate adjustment,
the specific calculation for the requested rate adjustment, and documentation
which supports the above; and
(iii)
The specific reasons, including references to a applicable federal and State
law, that justify the rate adjustment.
(b) Department's responsibilities.
(i) The Department shall acknowledge, in
writing, receipt of the request for rate adjustment within fifteen days after
receipt;
(ii) The Department may
request, in writing, additional information from that provider. The provider
must the requested information to the Department, by certified mail, within
sixty days after receipt of the request. Failure to timely provide the
requested information shall result in the dismissal, with prejudice, of the
request for rate adjustment.
(iii)
The Department shall review the request for rate adjustment to determine
whether the request meets any of the criteria set forth in subsection
(c).
(iv) Burden of proof. Except
as otherwise provided by these rules, the provider requesting a rate adjustment
shall bear the burden of proving by a preponderance of the evidence that it is
entitled to a rate adjustment.
(v)
Notice of final decision. The Department shall send written notice to the
provider, by certified mail, of its final decision within one-hundred eighty
days after the receipt of the request for rate adjustment or the receipt of any
additional information requested by the Department pursuant to (ii), whichever
is later. The provider may request an administrative hearing regarding the
decision of the Department pursuant to (g).
(c) Bases for rate adjustment. The Department
may grant a request for rate adjustment if the provider demonstrates that:
(i) There has been a significant increase in
the acuity of care provided by the hospital since the base year and the failure
to make a rate adjustment will result in recipients not having reasonable
access to inpatient hospital services of adequate quality;
(ii) Extraordinary circumstances occurring
since the base year have caused the provider to incur substantially higher
costs;
(iii) There has been an
error in the calculation of the provider's TEFRA cost per discharge target
amount;
(iv) The provider is
rendering atypical services;
(v)
The provider is located in an area with a significant change in the Medicaid
population during the year;
(vi)
The provider is engaged in an approved medical or paramedical education program
that has resulted in increased costs;
(vii) For cost reporting periods beginning
before October 19 z, the provider is rendering more intensive routine care
resulting in a shorter length of stay and higher per unit costs than in
comparable hospitals;
(viii)
Application of the limit would render a hospital insolvent, thereby depriving
the community of essential services (the hospital must have exceeded the limit
by more than fifteen percent);
(ix)
The provider is newly established home health agency (an agency certified for
Medicare less than three full years); or
(x) The provider has labor costs that vary by
more than ten percent from the labor costs that were used in promulgating the
limits.
(d) In
determining whether to grant a rate adjustment pursuant to subsection (c), the
Department shall consider:
(i) Whether the
provider has demonstrated that its unreimbursed costs are caused by factors
generally not shared by other Wyoming hospitals;
(ii) Whether the provider has taken every
reasonable step to control costs; and
(iii) Whether the provider's costs may be
controlled through good management practices or cost containment measures. In
determining whether the providers costs may be so controlled, the Department
may consider:
(A) Efforts to reduce or
contain employee benefits;
(B)
Efforts to consolidate or centralize personnel or departmental
functions;
(C) Efforts to review
departmental staffing levels and use lesser-skilled employees or reduce
full-time equivalent employees, without adversely affecting the quality of
patient care;
(D) Efforts to affect
physicians order patterns, e.g., through use of drug formularies, standardizing
supplies, and reducing unnecessary tests;
(E) Efforts to reduce reliance on agency or
registry personnel;
(F) Efforts to
expedite billing;
(G) Use of
volunteers and fund-raising;
(H)
Efforts to control costs;
(I)
Efforts to reduce the incidence of employee injuries;
(K) Efforts to reduce employee
turnover;
(L) Efforts to improve
efficiency through improved scheduling;
(M) Equipment sharing arrangements;
and
(N) The use of information or
management systems and procedures.
(e) Calculation of rate adjustment. If the
Department determines pursuant to subsection (d) that a hospital is entitled to
a rate adjustment for one of the reasons specified in subsection (c), the rate
adjustment shall be calculated as follows:
(i) The Department shall recalculate the
provider's target amount using the rate year for which the rate adjustment was
requested, unless the rate adjustment is based on extraordinary
circumstances.
(ii) If the rate
adjustment is based on extraordinary circumstances, the Department may increase
the per discharge ceiling by the amount necessary to meet the Medicaid share of
the net additional allowable costs incurred as a result of the extraordinary
circumstances.
(f)
Effect of rate adjustments.
(i) Rate
adjustments resulting from extraordinary circumstances shall be limited to the
fiscal period in question.
(ii)
Rate adjustments other than adjustments resulting from extraordinary
circumstances shall be limited to the fiscal period in question unless the
facility shows, for each succeeding rate period, that the conditions which
resulted in the rate adjustment still exist.
(g) Administrative hearing. A Provider may
request an administrative hearing regarding the final agency decision pursuant
to chapter I of these rules by mailing by certified mail or personally
delivering a request for hearing to the Department within twenty days after the
date the provider receives notice of the final agency decision.
(h) Failure to request rate adjustment. A
provider which fails to request a rate adjustment pursuant to this section may
not subsequently request an administrative hearing pursuant to Chapter I
regarding the decision to recover overpayments.
(i) Matters not subject to rate adjustment or
reconsideration. The following matters are not subject to a rate adjustment
pursuant to this section, reconsideration pursuant to Section 17, or an
administrative hearing pursuant to Chapter I:
(i) A recovery of overpayments caused by a
change in the reimbursement methodology as the result of a change in state or
federal law, including a change in these rules; or
(ii) The use or reasonableness of the
reimbursement methodology set forth in these rules.
