LeadingAge Ohio meets with staff of the Ohio Department of Medicaid (ODM) on a monthly basis. Below is a summary of this month’s updates.
MDS Exception Reviews:
Dan Hirschler, Program Manager reported that effective March 12, the MDS exception reviews will focus on the December 31 quarter instead of the September 30 quarter. With the change to the December 31 quarter, any modifications in case-mix score results from the reviews will be prospective (affecting the July 1, 2018 rate) instead of retrospective. As a result, providers will have the opportunity for reconsideration versus a formal hearing under Chapter 119 of the Revised Code. Mr. Hirschler shared the following update on the completed reviews as of March 1: Myers and Stauffer (ODM’s contracted vendor) has conducted exception reviews at 21 facilities; 14 of these reviews were “supported” and 7 “unsupported”. Of the 7 facilities with unsupported records, Myers and Stauffer reviewed 306 records and found 149 (49%) were not corroborated by medical record documentation. Conversely, for the facilities with supported records, only 8% of the 275 individual records reviewed were not validated by the medical record. Per Mr. Hirschler there were a few facilities with zero unsupported records.
Mr. Hirschler stated that ODM has sent three letters to nursing facilities informing them of the reduction in case-mix scores pursuant to the exception reviews. The letters are sent to the facility via certified mail and ODM will be allowing 30 days from the facility’s receipt of the letter for appeals, instead of 30 days from the date of mailing as currently written in rule.
Post Payment Audits
Mark Graves, Program Integrity ODM, shared that approximately 1300 letters will be sent to providers April 1, 2018 with each provider receiving a separate letter for SFY13 and SFY14. Of the 1300 with audit findings, the average overpayment amount is about $40,000, but ODM audit staff continue to review the amounts to determine if additional reductions can be made before mailing. Mr. Graves stated that ODM anticipates sending out letters to providers with no findings ($0 balance) to minimize calls they received from providers who were concerned that reports were lost in the mail, etc. As noted previously, providers should work with their assigned auditor over concerns regarding repayment and cash flow, especially given the fact that this is the first time ODM is processing two fiscal years at once.
Medicaid Managed Care Enrollment Issues
Medicaid NF residents may erroneously appear in MITS as enrolled in managed care plan. Nicole Northrup, Managed Care ODM, explained that if there is not a living arrangement code in Ohio Benefits that indicates that this individual is in a NF, there is nothing that prevents the system from enrolling a beneficiary who turns 65 into managed care. Ms. Northrup recommended that facilities with patients with this issue contact the county caseworker to ensure the appropriate living arrangement code is added. Ms. Northrup noted that this can be done without having to “run the case.” In addition, Ms. Northrup affirmed that the managed care plans are responsible to disenroll individuals who have been enrolled incorrectly once notified of the error and that the plans were notified that disenrollments would be retroactive to the month of the erroneous enrollment.
NF Payment Cap Update
Terry Moore, Chief, Rate Setting reported that ODM continues to work to reconcile the information received from the managed care plans and anticipates that the data on the fiscal year’s spending will be available soon. Ms. Moore indicated that ODM’s preliminary work appears to demonstrate that NF spending is below the cap.
LeadingAge Ohio encourages members to share questions they would like posed to ODM during its monthly meetings. Questions may be directed to Stephanie DeWees at sdewees@leadingageohio.org.