| (4) If a hospital's DSH payments are being held in
reserve on the date of the last payment in the DSH program year, and
no request for review is pending under paragraph (5) of this subsection,
the amount of the payments is not restored to the hospital, but is
divided proportionately among the hospitals receiving a last payment.
(5) Hospitals that have DSH payments held in reserve
may request a review by HHSC.
(A) The hospital's written request for a review must:
(i) be sent to HHSC's Director of Hospital Finance,
Provider Finance Department;
(ii) be received by HHSC within 15 calendar days after
notification that the hospital's DSH payments are held in reserve;
and
(iii) contain specific documentation supporting its
contention that it is in compliance with the conditions of participation.
(B) The review is:
(i) limited to allegations of noncompliance with conditions
of participation;
(ii) limited to a review of documentation submitted
by the hospital or used by HHSC in making its original determination;
and
(iii) not conducted as an adversarial hearing.
(C) HHSC will conduct the review and notify the hospital
requesting the review of the results.
(l) Recovery and redistribution of DSH funds. As described
in subsection (o) of this section, HHSC will recoup any overpayment
of DSH funds made to a hospital, including an overpayment that results
from HHSC error or that is identified in an audit. Recovered funds
will be redistributed as described in subsection (p) of this section.
(m) Failure to provide supporting documentation. HHSC
will exclude data from DSH calculations under this section if a hospital
fails to maintain and provide adequate documentation to support that
data.
(n) Voluntary withdrawal from the DSH program.
(1) HHSC will recoup all DSH payments made during the
same DSH program year to a hospital that voluntarily terminates its
participation in the DSH program. HHSC will redistribute the recouped
funds according to the distribution methodology described in subsection
(l) of this section.
(2) A hospital that voluntarily terminates from the
DSH program will be ineligible to receive payments for the next DSH
program year after the hospital's termination.
(3) If a hospital does not apply for DSH funding in
the DSH program year following a DSH program year in which it received
DSH funding, even though it would have qualified for DSH funding in
that year, the hospital will be ineligible to receive payments for
the next DSH program year after the year in which it did not apply.
(4) The hospital may reapply to receive DSH payments
in the second DSH program year after the year in which it did not
apply.
(o) Audit process.
(1) Independent certified audit. HHSC is required by
the Social Security Act (Act) to annually complete an independent
certified audit of each hospital participating in the DSH program
in Texas. Audits will comply with all applicable federal law and directives,
including the Act, the Omnibus Budget and Reconciliation Act of 1993
(OBRA '93), the Medicare Prescription Drug, Improvement and Modernization
Act of 2003 (MMA), pertinent federal rules, and any amendments to
such provisions.
(A) Each audit report will contain the verifications
set forth in 42 CFR §455.304(d).
(B) The sources of data utilized by HHSC, the hospitals,
and the independent auditors to complete the DSH audit and report
include:
(i) The Medicaid cost report;
(ii) Medicaid Management Information System data; and
(iii) Hospital financial statements and other auditable
hospital accounting records.
(C) A hospital must provide HHSC or the independent
auditor with the necessary information in the time specified by HHSC
or the independent auditor. HHSC or the independent auditor will notify
hospitals of the required information and provide a reasonable time
for each hospital to comply.
(D) A hospital that fails to provide requested information
or to otherwise comply with the independent certified audit requirements
may be subject to a withholding of Medicaid disproportionate share
payments or other appropriate sanctions.
(E) HHSC will recoup any overpayment of DSH funds made
to a hospital that is identified in the independent certified audit
as described in this subsection and will redistribute the recouped
funds to DSH providers in accordance with subsection (p) that received
interim payments, subject to the hospital-specific limits, as described
in subsections (q) and (l) of this section.
(F) Review of preliminary audit finding of overpayment.
(i) Before finalizing the audit, HHSC will notify each
hospital that has a preliminary audit finding of overpayment.
(ii) A hospital that disputes the finding or the amount
of the overpayment may request a review in accordance with the following
procedures.
(I) A request for review must be received by the HHSC
Provider Finance Department in writing by regular mail, hand delivery
or special mail delivery, from the hospital within 30 calendar days
of the date the hospital receives the notification described in clause
(i) of this subparagraph.
(II) The request must allege the specific factual or
calculation errors the hospital contends the auditors made that, if
corrected, would change the preliminary audit finding.
(III) All documentation supporting the request for
review must accompany the written request for review or the request
will be denied.
(IV) The request for review may not dispute the federal
audit requirements or the audit methodologies.
(iii) The review is:
(I) limited to the hospital's allegations of factual
or calculation errors;
(II) solely a data review based on documentation submitted
by the hospital with its request for review or that was used by the
auditors in making the preliminary finding; and
(III) not an adversarial hearing.
(iv) HHSC will submit to the auditors all requests
for review that meet the procedural requirements described in clause
(ii) of this subparagraph.
(I) If the auditors agree that a factual or calculation
error occurred and change the preliminary audit finding, HHSC will
notify the hospital of the revised finding.
(II) If the auditors do not agree that a factual or
calculation error occurred and do not change the preliminary audit
finding, HHSC will notify the hospital that the preliminary finding
stands and will initiate recoupment proceedings as described in this
section.
(2) Additional audits. HHSC may conduct or require
additional audits.
(p) Redistribution of Recouped Funds. Following the
recoupments described in subsection (o) of this section, HHSC will
redistribute the recouped funds to eligible providers. To receive
a redistributed payment, the hospital must be in compliance with all
requirements during the program year, meet the audit requirements
described in subsection (o) of this section, and have already received
a DSH payment in that DSH year of at least one dollar. For purposes
of this subsection, an eligible provider is a provider that has room
remaining in its final remaining Hospital-specific limit (HSL) calculated
in the audit findings described in subsection (o) of this section
after considering all DSH payments made for that program year. Recouped
funds from state providers will be redistributed proportionately to
eligible state providers based on the percentage that each eligible
state provider's remaining final HSL (calculated in the audit findings
as described in subsection (o) of this section) is of the total remaining
final HSL (calculated in the audit findings described in subsection
(o) of this section) of all eligible state providers. Recouped funds
from non-state providers may be redistributed proportionately to state
providers or eligible non-state providers as follows.
(1) For DSH program years 2011-2017 (October 1, 2011
- September 30, 2017) and for DSH program years 2020 and after (October
1, 2019 and after), HHSC will use the following methodology to redistribute
recouped funds:
(A) the non-federal share will be returned to the governmental
entity that provided it during the program year;
(B) the federal share will be distributed proportionately
among all non-state providers eligible for additional payments that
have a source of the non-federal share of the payments; and
(C) the federal share that does not have a source of
non-federal share will be returned to CMS.
(2) For DSH program years 2018-2019 (October 1, 2017
- September 30, 2019), HHSC will use the following methodology to
redistribute recouped funds.
Cont'd... |
