NPR Process / Appeals / Reopenings

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NPR Process / Appeals / Reopenings

• Jim Flowers
• DMA Audit Section
• November 9, 2006

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NPR Process

• DMA Audit Staff review Clifton Gunderson LLP
  audit work/work papers/cost report and have final
  acceptance
• DMA review may result in
• Acceptance
• Additional Questions
• Add / Delete / Revise Adjustments
• Potential Additional Fieldwork

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NPR Process

• Once accepted DMA will issue the Notice of
  Program Reimbursement per 42 CFR 405.1803
• Version of DMA NPRs
• Hospital Outpatient Settlement
• Inpatient Desk Review
• Inpatient / Outpatient Field Audit

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NPR Process

• Hospital Outpatient Settlement NPR
• NC State Plan, Attachment 4.19-B, Section 2a
• Prior to 10/01/2005 and State Plan Amendment
  05-015, Non-State Owned Settled to 80 Allowable
  O/P Cost
• Excludes UNC PCMH Hospitals
• Direct Settlement Impact
• NPR
• Appeal Rights Notification on Settlement
• Not an Audit

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NPR Process

• State Owned / Operated Hospitals plus UNC
  Hospitals and PCMH and are settled to 100
  allowable costs.
• Effective 10/01/2005 and with SPA 05-015,
  Critical Access Hospitals are also settled to
  100 allowable costs and will be field audited
  each year.
• All State Owned / Operated Hospitals plus UNC
  Hospitals and PCMH are field audited each year on
  inpatient and outpatient services.
• There is no separate NPR for Hospital Outpatient
  Settlement on State Owned Hospitals.

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NPR Process

• Inpatient Desk Review
• 42 CFR 447.253(g)
• Periodic audits / reviews of Medicaid Hospital
  Providers
• No Direct Settlement Impact
• NPR
• Appeal Rights Notification on Adjustments
• May Require Outpatient Settlement Revision

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NPR Process

• Inpatient/Outpatient Field Audit
• 42 CFR 447.253(g)
• Periodic audits / reviews of Medicaid Hospital
  Providers
• Settlement Impact
• NPR
• Appeal Rights Notification on Adjustments
• May Require Outpatient Settlement Revision

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NPR Process

• Attachment A included with applicable NPRs
• Primary document used by DMA to communicate with
  DHHS Controllers Office for AP / AR on Cost
  Report Settlements.
• Intended to reflect the current Net Payable / Net
  Receivable due to settlements and audits of cost
  reports.
• DMA noted problems in age of historical provider
  payments when clearing OP Settlement Backlog
  FY1997 FY2002.

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NPR Process

• Two levels of review
• Primary review of audit and workpapers
• Final review at signature of NPR and Attachment
  A.
• DHHS Controllers Office is forwarded a copy of
  the NPR and Attachment A when cost report /
  settlement is mailed to the provider.

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NPR Process

• All NPRs mailed via certified USPS
• Mailed to address on cost report
• If in doubt or question on address, mailed to
  address registered with EDS as the Medicaid
  provider number accounting address

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NPR Process

• Terminated / Bankrupt Provider NPRs
• Mailed to Medicaid provider number address of
  record for terminated cost report period
• Settlements due DMA on bankrupt or terminated
  providers are referred to the DHHS Controllers
  Office to follow cash management plan, including
  possible referral to NC Attorney General for
  collection efforts.

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Appeal Process

• Defined in the State Administrative Procedure
  Code 10A NCAC 22J.0102
• Will be cited in appropriate NPR
• Provider may request a Reconsideration Review
• Must be done within 30 days of receipt of NPR

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Appeal Process

• Calculation Errors or Cost Report Errors.
• If a settlement or issued cost report contains a
  noted error or miscalculation, the DMA Audit
  Section will work with the provider to correct
  the error and reissue the cost report or
  settlement outside of the appeals process.
• Examples of errors corrected outside of the
  appeals process
• Spreadsheet formula error
• Prior payment by provider not shown on Attachment
  A.

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Appeal Process

• For issues which are not errors, the specific
  address and Hearings Officer point of contact are
  identified in the NPR Letter.
• Requests must be in writing.
• Requests received in excess of 30 days may be
  denied.
• Requests without specific dissatisfactions (i.e.
  blanket appeals) noted will be denied.

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Appeal Process

• Hospital Outpatient Settlements are performed and
  issued as a settlement. These are not field
  audits and therefore have no Audit Adjustment
  Report.
• For Outpatient Settlements, the schedules are
  recalculated and reissued based on the providers
  Medicaid cost report and updated paid claims
  information.
• Hospital Outpatient Settlements may be appealed
  however, the provider must state the specific
  issue with which they disagree (i.e. proper
  mapping of revenue codes) as there will not be a
  specific audit adjustment.

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Appeal Process

• Appeal received by the Hearings Officer are
  logged and a response is sent to the provider
  noting that their appeal has been accepted.
• From this point the appeal rights have been
  reserved and DMA will attempt an informal
  resolution with members of the DMA Audit staff
  and/or Clifton Gunderson.
• Significant number of appeals received and
  currently being worked.
• Most appeals concern Long Term Care Providers

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Appeal Process

• Typically appeals fall into two main categories
  and these would warrant a written request to the
  Hearings Officer within 30 days to preserve the
  providers appeal rights
• Documentation
• Interpretation

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Appeal Process

• Documentation Appeal
• Missing documentation
• Requested supporting documentation not received
  timely to complete audit
• Incorrectly supplied documentation
• Typically can be resolved outside of an
  Administrative Conference via provider submission
  and DMA review of applicable documentation

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Appeal Process

• Interpretation Appeal
• Involves different interpretation of existing
  policy, regulations, or laws.
• Involves interpretation of whether cost report
  data as filed by the provider meets existing
  policy, regulations, or laws.
• Typically is not resolved outside of an
  Administrative Conference and positions will be
  presented to the Hearings Officer.

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Appeal Process

• DMA and/or Clifton Gunderson will issue
  correspondence to the provider stating the
  position, documentation, and applicable
  regulation on each contested adjustment.
• If there are applicable workpapers the provider
  does not have or has requested, those will be
  enclosed.
• DMA may reverse or revise an adjustment based on
  review of documentation submitted by the provider
  with the Appeal. If so, this will also be noted
  in the correspondence.
• The provider will be given a reasonable time
  period to respond to the correspondence however,
  DMA / CG and the provider may still disagree.

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Appeal Process

• If DMA / CG and the provider reach an impasse on
  one or more adjustments, DMA will communicate
  this impasse to the Hearings Officer and an
  Administrative Conference will be scheduled.
• Conference date will be 30-60 days after an
  impasse has been communicated. Mutually
  agreeable time and date.
• The Hearings Officer will typically request
  written positions and applicable documentation
  from DMA/CG and the provider on each of the
  contested issues and these are typically required
  no later than 14 days prior to the scheduled
  Conference date.

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Appeal Process

• The Administrative Conference is a non-legal
  proceeding as such legal counsel is not
  required. However, if the provider intends to
  bring legal counsel to the Conference, they are
  required to inform the Hearings Officer in a
  timely manner.
• Administrative Conferences are normally conducted
  in person however, providers have the option to
  conduct the Administrative conference via
  teleconference.

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Appeal Process

• The Administrative Conference is an attempt for
  an independent DMA Hearings Officer to hear both
  sides of appealed issues and render the final
  informal agency decision for DMA.
• The Hearings Officer Decision will be
  communicated to the provider in a Decision
  Letter, outlining the position and determination
  of each appealed issue.

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Appeal Process

• The Hearings Officer will issue one of four
  possible determinations on each appealed issue
• Sustain DMA Audit Sections adjustment
• Overturn DMA Audit Sections adjustment
• Allow provider to withdraw an appealed adjustment
• Allow DMA and provider to reach a non-precedent
  compromise on the adjustment

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Appeal Process

• If the Hearings Officer overturns any adjustment
  or a compromise is reached at the Administrative
  Conference, the DMA Audit Section will revise and
  reissue the appropriate cost report or settlement
  under a new NPR (without appeal rights noted as
  appeal rights have already been exercised).
• If the provider disagrees with the DMA Hearings
  Officer Decision, specific language and
  regulatory citation will be included in the
  Decision Letter instructing the provider on how
  to appeal the Decision to the Office of
  Administrative Hearings (OAH).
• Any appeals to OAH must be done within 60 days of
  the Decision Letter.

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Appeal Process

• Appeals to the Office of Administrative Hearings
  will be represented by DMA Counsel at the NC
  Attorney Generals Office.
• Recent courses of action on Appeals to OAH
• Hearing before Administrative Law Judge
• Ordered Mediation

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Reopening Process

• 10A NCAC 22J.0102 identifies when the state
  agencys actions become final in absence of an
  appeal or timely Petition for Reconsideration
  Review. (Appeal rights citation in providers
  NPR)
• Reopenings will be reviewed in accordance with
  the Provider Reimbursement Manual (CMS 15-1)
  Sections 2931 and 2932 as appropriate.

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Reopening Process

• Timelines for reopening an Intermediary (DMA)
  decision will be within three years of the date
  of the NPR.
• If a reopening of a cost report is pursued by a
  provider, the request should be addressed to the
  DMA Audit Section point of contact listed on the
  NPR.

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Reopening Process

• Reopening based upon Medicare Audit Findings.
• Settlements, Desk Reviews, and Field Audits are
  initially conducted based upon parallel review
  with the As Filed Medicare cost report.
• Desk Reviews Field Audits request copies of
  audited Medicare cost reports if completed and
  will incorporate material adjustments into the
  Medicaid cost report.
• Providers may request a reopening based on
  Medicare audit findings completed subsequent to
  Medicaid audit processes. A full copy of the
  audited Medicare cost report with all adjustments
  must be filed with the request to DMA.

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Reopening Process

• Limitations on Amended Cost Reports as identified
  in CMS 15-1, Section 2931.2 are applicable.
• Material errors discovered subsequent to filing
• Comply with health insurance policies /
  regulations
• Reflect settlement of a contested liability
• Notice of Refusal to Reopen or Correct, CMS 15-1,
  Section 2932.1

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Reopening Process

• Limitations on Amended Cost Reports as identified
  in CMS 15-1, Section 2931.2 are applicable.
• Material errors discovered subsequent to filing
• Comply with health insurance policies /
  regulations
• Reflect settlement of a contested liability
• Except to comply with health insurance policies /
  regulations, the provider may not file an
  amended cost report to avail itself of an option
  it did not originally elect.

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Reopening Process

• Notice of Refusal to Reopen or Correct, CMS 15-1,
  Section 2932.1
• Notice to be furnished on finding by DMA that a
  reopening is not warranted.
• CMS 15-1, Section 2931.2
• Final determinations will not be reopened simply
  because a different view is taken with respect to
  the import of evidence upon which a determination
  was made.

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NPR Process - Working Issues

• Finalization of all FY1997 FY2002 Hospital
  Outpatient Settlements incomplete from BCBS
  Common Audit Agreement.
• Coordination with Clifton Gunderson of FY2003 and
  forward NPR Process on hospitals with Outpatient
  Settlements and also selected for Desk Review or
  Field Audit.
• Coordination with DHHS Controllers Office on
  historical AP and AR for the Attachment As.

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Appeal Process - Working Issues

• Appropriate Staff / Management in place at
  Clifton Gunderson LLP to adequately address cost
  report appeals
• Coordination of documentation with providers
• Full Recap of all adjustments
• Timelines for documentation requests
• PSR Mapping Issues
• Addressed timely by DMA / Contractor
• CRNA appeals in progress