Ohio Admin. Code 5160-57-04 - Medicaid provider incentive program (MPIP): program integrity and provider appeals
(A) Program integrity.
(1) MPIP legal notice.
(a) All eligible professionals and eligible
hospitals submitting an application to receive an MPIP payment are required to
sign the MPIP legal notice before confirming and submitting their
application.
(b) All program
applicants are bound by the requirements of the MPIP legal notice.
(2) Eligible professional and
eligible hospital MPIP applications and attestations are subject to
verification by the Ohio department of medicaid (ODM).
(3) For any given payment year an eligible
professional and eligible hospital must register for MPIP by the end of the
calendar year (CY) for an eligible professional and federal fiscal year (FFY)
for an eligible hospital.
(4) An
eligible professional and eligible hospital will have sixty days after the end
of the CY for an eligible professional and FFY for and eligible hospital to
complete attestation via the MPIP system for a given payment year.
(5) Post payment audits and record retention.
(a) An eligible professional's and eligible
hospital's MPIP application and attestation are subject to a post payment
audit.
(b) ODM or its designee, the
state auditor's office, the state attorney general's office and the federal
centers for medicare and medicaid services (CMS) may conduct reviews and audits
of MPIP applications for the purpose of determining compliance with the
requirements of this chapter as well as with applicable state and federal
requirements.
(c) Audits and
reviews may be conducted on-site as determined necessary based on periodic
analysis of medical, financial, and other information.
(d) Records stored electronically must be
produced at the eligible professional's or eligible hospital's expense, upon
request, in the format specified by ODM.
(e) All records must be maintained for a
minimum of seven years following the last day of the CY for eligible
professionals or FFY for eligible hospitals in which payment related to the
attestation has been received, or in the event that the eligible professional
or eligible hospital has been notified that state or federal authorities have
commenced an audit or investigation of their MPIP application, until such time
as the matter under audit, appeal or investigation has been resolved.
(f) An eligible professional and eligible
hospital must comply with all audit recoveries.
(6) Fraud, waste, and abuse.
(a) Suspicion or detection of fraud and abuse
by ODM will be referred to the medicaid fraud control unit (MFCU) in the office
of the attorney general (AG). Referrals to the MFCU will be investigated for
prosecutorial merit.
(b)
Substantiated cases of fraud and abuse will be prosecuted according to federal
and state regulations.
(B) Provider appeals.
(1) An eligible professional or eligible
hospital may appeal the following issues related to MPIP, by first requesting
an informal review:
(a) Incentive payment
amounts.
(b) Provider eligibility
determinations (i.e. patient volume, hospital-based).
(c) Demonstration of adoption,
implementation, or upgrade, and meaningful use eligibility.
(2) Appeals filed after the
deadlines specified in paragraphs (B)(3)(a) and (B)(4)(a) of this rule, will be
dismissed without the ability to refile. If the deadline falls on a saturday,
sunday, state or federal holiday, the period for requesting an appeal will be
extended to the next business day.
(3) Informal review.
(a) If the MPIP system has made a preliminary
determination that may be adverse regarding the incentive payment application
of an eligible professional or eligible hospital, the eligible professional or
eligible hospital may request an informal review of the preliminary
determination via the MPIP system, within fifteen calendar days of notification
of an adverse preliminary determination.
(b) A request for informal review shall be
made via the MPIP system and may include supporting documentation to support
the request.
(c) An eligible
professional or eligible hospital will be notified of the informal review
decision via email and will be advised to log into the MPIP system to see the
details of the review decision.
(d)
An eligible professional or eligible hospital may withdraw the request for an
informal review via the MPIP system, without reason, at any time, after the
initial filing and before an informal review decision is issued.
(4) Request for reconsideration.
(a) If the informal review upholds the
preliminary adverse determination and the eligible professional or eligible
hospital does not agree with the informal review decision, the eligible
professional or eligible hospital may submit a written request for
reconsideration no later than fifteen calendar days after the date of
notification of determination via the MPIP system.
(b) The request for reconsideration shall be
initiated via the MPIP system and must include a written and signed letter from
the eligible professional or eligible hospital containing the following
information:
(i) Clear identification of the
affected eligible professional or eligible hospital;
(ii) The proposed action being
contested;
(iii) The basis for
requesting reconsideration; and
(iv) Supporting documentation being
submitted.
(c) The
written request for reconsideration must be signed, dated, include any
supporting documentation and must be uploaded via the MPIP system.
(d) An eligible professional or eligible
hospital will be notified in writing, by certified mail, of the reconsideration
decision.
(5) In
accordance with Chapter 2505. of the Revised Code, an eligible professional or
eligible hospital may appeal the reconsideration decision by filing a notice of
appeal with the court of common pleas of Franklin county. The notice shall
identify the decision being appealed and the specific grounds for the appeal.
The notice of appeal shall be filed not later than fifteen days after the
department mails its notice of the reconsideration decision. A copy of the
notice of appeal shall be filed with the department not later than three days
after the notice is filed with the court.
Notes
Promulgated Under: 119.03
Statutory Authority: 5162.02, 5164.93
Rule Amplifies: 5164.93
Prior Effective Dates: 1/1/2012, 9/10/2012, 10/1/2013
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