(a) The following
words and terms, when used in this section, shall have the following meanings,
unless the context clearly indicates otherwise:
"Alternative documentation adjustment" means an adjustment to
a hospital's charity care write-off amount as a result of the periodic audits
of a sample of claims submitted during a calendar year. This audit determines
whether the total value of sampled claims that are documented by the
alternative procedures described in
N.J.A.C.
10:52-11.6(a)3, 11.7(a)3,
11.9(a)3 or 11.10(d)3, exceeds permitted limits.
"Charity care write-off amount" means the rendered charity
care services, priced at the rate used by the Medicaid program before
adjustment, if any, for direct graduate medical education and indirect medical
education factors.
"Compliance adjustment" means an adjustment to a hospital's
charity care write-off amount as a result of the periodic audits of a sample of
claims submitted during a calendar year. This audit determines whether there is
appropriate documentation showing that all charity care eligibility
requirements at
N.J.A.C.
10:52-11.5 through 11.11 and 11.16 have been
met.
"Listing adjustment" means an adjustment to a hospital's
charity care write-off amount as a result of the audit of a sample of these
claims submitted during a calendar year. The purpose of this audit is to ensure
that the claims contain only those charges that are eligible for
reimbursement.
(b) The
charity care write-off amount for each account should agree with the
reimbursement rate that would have been paid to the hospital by the Medicaid/NJ
FamilyCare program. To the extent that a hospital's total charity care
write-off amount is overstated, the amount will be reduced by the amount of the
overstatement.
(c) In addition to
adjustments required to ensure that the charity care write-off amount is equal
to the Medicaid/NJ FamilyCare reimbursement rates, the write-off amount may
also be revised on the basis of listing, alternative documentation and/or
compliance adjustments, in that order.
(d) Examples of listing adjustments include
changes made if:
1. Medicare or other
third-party payer payments were not reflected in the claim;
2. Ineligible expenses, such as standard
convenience or personal comfort items as listed in Uniform Billing
requirements, are included; or
3.
The percentage of the claim to be written off to charity care, based on the
hospital's determination of the applicant's eligibility, was
erroneous.
(e) In
accordance with the provisions of
N.J.A.C.
10:52-11.11, use of alternative documentation
in any one of the steps to determine an applicant's eligibility for charity
care shall cause that applicant's file to be designated as an alternative
documentation file. A ratio shall be developed using sample dollars with
alternative documentation as a percentage of total sample dollars. If this
ratio is less than or equal to.10, there shall be no adjustment. If this ratio
is greater than.10, the ratio shall be reduced by.10 and then multiplied by the
hospital's charity care write-off amount at the Medicaid/NJ FamilyCare rate for
the calendar year being audited. This amount shall be subtracted from the
hospital's charity care write-off amount for the calendar year being audited at
the Medicaid rate after listing adjustment.
(f) In accordance with the provisions of
N.J.A.C.
10:52-11.5 through 11.11, noncompliance with
any one of the steps to determine an applicant's eligibility for charity care
shall cause that applicant's file to be designated as a failed compliance file.
A ratio shall be developed using sample dollars from failed compliance files as
a percentage of total sample dollars. If this ratio is less than.10, there
shall be no adjustment. If this ratio is equal to or greater than.10, the ratio
shall be multiplied by the hospital's charity care write-off amount for the
calendar year being audited at the Medicaid/NJ FamilyCare rate. This amount
shall be subtracted from the hospital's charity care write-off amount at the
Medicaid rate after alternative documentation adjustment.
(g) The hospital's charity care write-off
amount total adjusted for (d), (e) and (f) above will constitute the hospital's
audited charity care write-off amount for claims submitted during the calendar
year being audited, except for further adjustments that may occur in accordance
with N.J.A.C.
10:52-13.4.
(h) The Department of Health's auditor will
provide the hospital with a copy of its audit findings and recommended
adjustments. Eligible hospitals shall sign the auditor's audit findings,
indicating their agreement or disagreement with the audited charity care
write-off amount. If the hospital disagrees with the audit findings, the
hospital shall submit a request for a departmental review within 15 days of
receiving the auditor's report and shall, within the request, detail the
reasons for disagreement with the auditor's findings. The Department will
review the auditor's findings, as well as the hospital's objections, and will
advise the hospital within 30 days of receipt of the request for review of the
total dollar value of the hospital's charity care write-off for the period
audited, priced at the Medicaid/NJ FamilyCare rate.
(i) A hospital which disagrees with the audit
findings may request an administrative hearing, which shall be conducted in
accordance with the Administrative Procedure Act,
N.J.S.A.
52:14B-1 et seq., and the Uniform
Administrative Procedure Rules, N.J.A.C. 1:1.
