02/14/2018

ODM Meeting: Patient Liability, Quick Compliance Checks, Overpayment Reports, Exception Reviews

Last week, LeadingAge Ohio staff met twice with representatives of the Ohio Department of Medicaid (ODM) on various regulatory issues. The following are updates from the call: 

Al Dickerson, Chief, Rate Setting and Cost Reporting reported that ODM is continuing to evaluate how it will implement certain HB 49 provisions such as index maximization, antipsychotic exemption for hospice patients and NF payment caps. 

With regards to the use of index maximization ODM had Myers & Stauffer conduct an analysis of 2017 Q1-3 data. Preliminary data show that there is approximately a 70 cent difference in the positive between index maximizer and hierarchical calculations. Mr. Dickerson stated that ODM would like to have more experience with the data in order to make an informed choice. 

ODM continues to work through Ohio’s MDS data to calculate a NF’s antipsychotic measure with the exclusion of hospice patients.  ODM is also working on ensuring accurate data on the nursing facility (NF) payment calculation.  ODM has reviewed internal NF encounter data (for both fee-for-service and MyCare), but has reached out to the MyCare Ohio plans to compare its data analysis with the plans’ MyCare Ohio data.

Terry Moore, Chief, Rate Setting, indicated that ODM has provided guidance to the plans to identify the core set of revenue codes that the NF can use to bill. Ms. Moore reported that ODM is seeing a variety of codes through their encounter data, some of which are not part of the core set. ODM will continue to evaluate and update the associations. 

Rule Changes. Three rule packages (tax cost add-on, ventilator rule related to payment for vent weaning and 9401) are under development and are expected in coming days. LeadingAge Ohio will review the rules and provide feedback as indicated.           

Patient liability (PL). ODM has been meeting with managed care plans regarding both their current practices as well as the backlog of patient liability issues. ODM shared that all of the MyCare Ohio plans have edits in their system designed to kick out past dates. Because of this, facilities need to contact plans, so the plan can let them know the manual process to get paid. This applies to the patient liability backlog (2014-July 2016). Additionally, it may also apply to more-recent outstanding patient liability, but providers will need to contact plans directly, since each one may have slightly different practices and edits in place. 

Patient liability draft document. The associations provided the following points to clarify current challenges with patient liability:

• The draft should provide clarification on instances when patient liability amounts are collected by one provider and need to be transferred to another provider.  This typically would occur when a resident transfers from one provider to another.
• The draft should provide clarification on the procedure when the patient liability has been collected by the facility, as this now becomes the responsibility of the facility and any refund to Medicaid.
• Managed care organizations don’t seem to know how to handle patient liability when a resident dies and patient liability is prorated.

The associations affirmed that a streamlined process for managed care PL that mirrors the fee-for-service process would be beneficial. 

Issues of re-enrollment in Medicaid Managed Care Plans
In response to stakeholder concerns that beneficiaries under the age of 65 were being re-enrolled in Medicaid managed care plans, ODM noted that whether a beneficiary would be reassigned depended on the “living arrangements” field in Ohio Benefits. If the living arrangements field in Ohio Benefits did not indicate that the individual resided in a nursing facility, then the individual would be assigned a managed care plan.  If providers are having an issue, please contact the county caseworker to ensure this living arrangement field is appropriately completed. ODM will investigate this matter further, and ask technical assistance to provide a memo or guidance. 

Quick Compliance Checks and Overpayment Reports
As part of ODMs efforts to get a better understanding of how providers have been documenting PL as part of the audit process, ODM is completing “quick compliance checks”.  Mark Graves, ODM shared that two quick compliance checks have been completed in the Cincinnati area, with no major issues discovered. These compliance checks are planned and announced visits, coordinated with providers to impose minimal disruption. ODM is still evaluating the methodology as it is early in the process. No major PL issues noted to date. The associations reiterated that providers are being encouraged to keep screenshots of MITS.  

ODM plans to release 1, 334 post payment claims (audit) reports for FY 13 and 14 to nursing facilities on April 1, 2018. It is anticipated that approximately 130 ICF reports will also be included in the April 1 mailing. Based on an initial review of the 1,300 plus reports, prior to auditors having having the chance to scrub the reports, the average is about $50,000 per report. 

Exception Reviews. Stakeholders have asked for clarification on the selection criteria used by Myers & Stauffer to identify facilities for exception review surveys. While rule specifies several criteria (e.g. change in case mix index [CMI]), Myers & Stauffer is using its own algorithm to develop a risk profile. The risk profile would include some of the rules criteria, but it is not limited to any one in particular. The risk profile likely includes change in CMI, potentially payor source trends, and other factors. 

The initial letters on exception review findings are expected to go out next week. The timetable for appeals will be based on the date the letter is sent. 

One Myers & Stauffer reviewer had initially used the SDR manual rather than the RAI manual, but this error in approach has been corrected. The pace of reviews has changed, with four last week, compared to two the weeks prior.  ODM shared that their initial estimate had been low, since they had not counted on Myers and Stauffer employing more reviewers to complete the work. ODM expects Myers & Stauffer to have surveyed 85-95 providers by June. ODM shared that there is a wide variation in facilities’ performance to date, with some doing very well on the reviews. 

Let us know your concerns/questions. LeadingAge Ohio meets with the Ohio Department of Medicaid the first week of every month. If you have questions you would like raised with the Department, email them to Nisha Hammel, Director of Advocacy at nhammel@leadingageohio.org and/or Stephanie DeWees, Quality & Regulatory Specialist for Long-term Care at sdewees@leadingageohio.org.