Or. Admin. Code § 410-125-1060 - Fiscal Audits
(1) Year-end
fiscal audits will include retrospective examination and verification of claims
and the determination of allowable charges and costs of hospital services
provided to Division clients.
(2)
The principal source document for the fiscal audit of Title XIX/Title XXI and
General Assistance patient billings and payments for a given fiscal period is
the Division data processing printout. This printout includes all transactions
for the audit period. Using gross totals from this printout and applying other
information from the Division records, information received from the hospital,
and other sources, the Division will compile detailed schedules of adjustments
and revise the gross totals. A revised Calculation of Reasonable Cost Statement
(DMAP 42) will be prepared using revised totals and information from the
Medicare report.
(3) Cost
Settlements: the Division will send the hospital a letter stating the amount of
underpayment or overpayment calculated by the Division for the fiscal year
examined. The letter will also state the hospital's inpatient/outpatient
interim reimbursement rate for the period from the effective date of the change
until the next fiscal year's audit is completed. Payment of the cost-settlement
amount is due and payable within 30 days from the date of the letter.
(4) The Division, at its discretion, may
grant a (30) thirty-day extension for the purpose of reviewing the cost
settlement upon a written request by the hospital. If a (30) thirty-day
extension is granted, payment of the cost settlement amount is due within sixty
(60) days from the date of the letter. If the provider chooses to appeal the
decision or rate, a written request for an administrative review, or contested
case must be received by the Division within (30) thirty-days of the date of
the letter notifying the hospital of the settlement amount and interim rate, or
within sixty (60) days if the Division has granted a thirty (30) day extension,
not withstanding the time limits in OAR
410-120-1580(3)
or 410-120-1660(1). Upon receipt of the request, the Division will attempt to
resolve any differences informally with the provider before scheduling the
administrative review or hearing.
(5) Under extraordinary circumstances, the
Division, at its discretion, may negotiate a repayment schedule with a
hospital. The hospital may be required to submit additional information to
support the hospital's request for a repayment schedule. The hospital will be
required to pay interest associated with extended payments granted by the
Division.
(6) The revised
Calculation of Reasonable Cost, copies of adjustment schedules, and a copy of
the printout are available to the hospital upon request. For Type A rural
hospitals the Calculation of Reasonable Cost Statement will reflect the
difference between payment at 100% of costs and payment for dates-of-services
on or after January 1, 2006 under the fee schedule for clinical laboratory
services provided by the hospital. An adjustment to the Cost Settlement will be
made to reimburse a Type A hospital at 100% of costs for laboratory and
radiology services provided to Medical Assistance Program clients during the
period the hospital was designated a Type A hospital. Settlements to Type B and
Critical Access hospitals will be made within the legislative
appropriation.
(7) The adjusted
Professional Component Cost-to-Charge ratio(s) will be applied to all
corresponding revenue code charges as listed on the Hospital Claim Detail
Reports for cost settlements finalized on or after October 1, 1999.
(8) Hospital Based Rural Health Clinics shall
be subject to the rules in the Hospital Services for the Oregon Health Plan
Guide for Type A and B Hospitals. Hospital Based Rural Health Clinics cost
settlements for dates of service from January 1, 2001 shall be finalized to
cost.
(9) No interim settlements
will be made. No settlements will be made until after receipt and review of the
audited Medicare cost report.
Notes
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
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