Reimbursement shall not exceed the reasonable cost of federally
qualified health center services and other ambulatory services covered under
the Kansas medical assistance program. "Reasonable cost" shall consist of the
necessary and proper cost incurred by the provider in furnishing covered
services to program beneficiaries, subject to the cost principles and limits
specified in
K.A.R.
129-5-118a(c)(1) and
K.A.R.
129-5-118b.
(a) Reimbursement method. An interim per
visit rate shall be paid to each federally qualified health center
provider,
with a retroactive cost settlement for each facility fiscal year.
(1) Interim reimbursement rate. The source
and the method of determination of interim rate shall depend on whether the
federally qualified health center is a new en-rollee of the Kansas medical
assistance program or is a previously enrolled
provider. Under special
circumstances, the interim rate may be negotiated between the agency and the
provider.
(A) Newly enrolled facility. If the
facility is an already-established federally qualified health center with an
available medicare cost report, an all-inclusive rate derived from the cost
report may be used for setting the initial medicaid interim payment rate. If
the facility is an already-established federally qualified health center
opening a new service location, then the rate from the already-established
federally qualified health center shall be used for the new service location.
If the facility converted from a rural health clinic to a federally qualified
health center, then the rate from the rural health clinic shall be used for the
new federally qualified health center. For all other circumstances, the initial
payment rate shall be based on the average of the current reimbursement rates
for previously enrolled federally qualified health center providers.
(B) Previously enrolled facility. After the
facility submits a federally qualified health center cost report, the agency
shall determine the maximum allowable medicaid rate per visit as specified in
subsection (c). If a significant change of scope of services or a significant
capital project has been implemented, the federally qualified health center
shall submit an interim cost report if the center wants a change to the
existing rate. The agency and the federally qualified health center shall use
the interim cost report to negotiate a new interim rate.
(2) Visit. A "visit" shall mean face-to-face
encounter between a center patient and a center health care professional as
defined in K.A.R.
129-5-118 . Encounters with more than one health professional
or multiple encounters with the same health professional that take place on the
same
day shall constitute a single visit, except under either of the following
circumstances:
(A) The patient suffers an
illness or injury requiring additional diagnosis or treatment after the first
encounter.
(B) The patient has a
different type of visit on the same day, which may consist of a dental,
medical, or mental health visit.
(3) Retroactive cost settlement. For each
reporting period, the agency shall compare the total maximum allowable medicaid
cost with the total payments to determine the program overpayment or
underpayment. Total payments shall include interim payments, third-party
liability, and any other payments for covered federally qualified health center
services. The cost report and supplemental data submitted by the provider, the
medicare cost report, and the medicaid-paid claims data obtained from the
program's fiscal agent shall be used for these calculations.
(b) Cost reporting. Each federally
qualified health center shall submit a completed cost report. The form used for
cost reporting shall be the most current version of the medicare financial and
statistical report form for independent rural health clinics and freestanding
federally qualified health centers with adjustments made, as necessary, to
report the cost and number of visits for medi-caid-covered services pursuant to
K.A.R.
129-5-118 .
(1) Filing requirements.
Each
provider shall be required to file annual cost reports on a fiscal year
basis.
(A) Cost reports shall be received no
later than five months after the end of the facility's fiscal year. An
extension in due date may be granted by the agency upon request, if necessary
due to circumstances beyond the control of the federally qualified health
center.
(B) Each
provider filing a
cost report after the due date without a preapproved extension shall be subject
to the following penalties:
(i) If the cost
report has not been received by the agency by the close of business on the due
date, all further payments to the provider may be withheld and suspended until
the complete financial and statistical report has been received.
(ii) Failure to submit the completed
financial and statistical report within one year after the end of the cost
report period may be cause for termination from the Kansas medical assistance
program.
(2)
Fiscal and statistical data. The preparation of the cost report shall be based
upon the financial and statistical records of the facility and shall use the
accrual basis of accounting. The reported data shall be accurate and adequately
supported to facilitate verification and analysis for the determination of
allowable costs.
(3) Supplemental
data. The following additional information shall be submitted to support
reported data and to facilitate cost report review, verifications, and other
analysis.
(A) A working trial balance. This
balance shall contain account numbers, descriptions of the accounts, the amount
of each account, the cost report expense line on which the account was
reported, and fiscal year-end adjusting entries to facilitate reconciliation
between the working trial balance and the cost report. The facility shall bear
the burden of proof that the reported data accurately represents the cost and
revenue as recorded in the accounting records. All unexplained differences
shall be used to reduce the allowable cost.
(B) Financial statements and management
letter. These documents shall be prepared by the facility's independent
auditors and shall reconcile with the cost report.
(C) Depreciation schedule. This schedule
shall support the depreciation expense reported on the cost report.
(D) Other data. Data deemed necessary by the
agency for verification and rate determination shall also be
submitted.
(c) Determination of reimbursable medicaid
rate per visit.
(1) Allowable facility costs.
This term shall mean costs derived from reported expenses after making
adjustments resulting from cost report review and application of the cost
reimbursement principles specified in K.A.R.
129-5-118b .
(2) Allocation of overhead costs.
(A) Total allowable administrative and
facility costs shall be distributed to the following cost centers:
(i) Federally qualified health center
costs;
(ii) non-federally qualified
health center costs; and
(iii)
nonreimbursable costs, excluding bad debt.
(B) Accumulated direct cost in each cost
center shall be used as the basis for the overhead cost allocation.
(3) Average allowable cost per
visit. The total allowable facility costs shall be divided by the total number
of visits.
(4) Reimbursable
medicaid rate. The reimbursable medicaid rate per visit shall not be more than
100 percent of the reasonable and related cost of furnishing federally
qualified health center services covered in K.A.R.
129-5-118b .
(d) Fiscal and statistical records
and audits.
(1) Recordkeeping. Each provider
shall maintain sufficient financial records and statistical data for accurate
determination of reasonable costs. Standardized definitions and reporting
practices widely accepted among federally qualified health centers and related
fields shall be followed, except to the extent that these definitions and
practices may conflict with or be superseded by state or federal medicaid
requirements.
(2) Audits and
reviews.
(A) Each
provider shall furnish any
information to the agency that may be necessary to meet the following criteria:
(i) Ensure proper payment by the program
pursuant to this regulation and K.A.R.
129-5-118b ; and
(ii) substantiate claims for program
payments.
(B) Each
provider shall permit the agency to examine any records and documents necessary
to ascertain information for determination of the accurate amount of program
payments. These records shall include the following:
(i) Matters of the facility ownership,
organization, and operation;
(ii)
fiscal, statistical, medical, and other recordkeeping systems;
(iii) federal and state income tax returns
and all supporting documents;
(iv)
documentation of asset acquisition, lease, sale, or other
transaction;
(v) management
arrangements;
(vi) matters
pertaining to the cost of operation; and
(vii) health center financial
statements.
(C) Other
records and documents shall be made available to the agency as
requested.
(D) All records and
documents shall be available in Kansas.
(E) Each provider shall furnish to the
agency, upon request, copies of patient service charge schedules and any
subsequent changes to these schedules.
(F) The agency shall suspend program payments
if it is determined that a provider does not maintain adequate records for the
determination of reasonable and adequate rates under the program or if the
provider fails to furnish requested records and documents to the
agency.
(G) Thirty days before
suspending payment to the provider, written notice shall be sent by the agency
to the provider of the agency's intent to suspend payment. The notice shall
explain the basis for the agency's determination and identify the provider's
recordkeeping deficiencies.
(H) All
provider records that support reported costs, charges, revenue, and patient
statistics shall be subject to audits by the agency, the United States
department of health and human services, and the United States general
accounting office. These records shall be retained for at least five years
after the date of filing the cost report with the agency.
Notes
Kan. Admin. Regs. §
129-5-118a
Authorized by K.S.A. 2008
Supp. 75-7403 and
75-7412; implementing K.S.A. 2008
Supp. 75-7405 and
75-7408; effective March 19,
2010.