| (ii) If the hospice representative is not present during
the exit conference, the OIG provides formal written notification
of all RUG-III changes within 15 calendar days of the exit conference.
(iii) If the nursing facility disagrees with the HHSC
RUG-III determination or assessment of errors, the nursing facility
may submit a request for reconsideration as provided in subsection
(q) of this section.
(o) The OIG may sanction any provider or person as
defined in §371.1 of this title (relating to Definitions), including
a managed care organization or subcontractor, pursuant to Subchapter
G of this chapter that:
(1) fails to grant immediate access upon reasonable
request to:
(A) the OIG;
(B) the OAG's Medicaid Fraud Control Unit or Civil
Fraud Division;
(C) any state or federal agency authorized to conduct
compliance, regulatory, or program integrity functions on the provider,
person, or the services rendered by the provider or person; or
(D) any agent or consultant of any agency or division
within an agency described in subparagraph (A) of this paragraph;
(2) fails to allow the OIG or any other federal or
state agency, division, agent, or consultant, as described in paragraph
(1) of this subsection to conduct any duties that are necessary to
the performance of their statutory functions; or
(3) fails to provide to the OIG or any other federal
or state agency, division, agent, or consultant, as described in paragraph
(1) of this subsection, upon request and as requested, for the purpose
of reviewing, examining, and securing custody of records, access to,
disclosure of, and custody of:
(A) copies or originals of any records, documents,
or other requested items, as determined necessary by the OIG or those
specified in paragraph (1) of this subsection to perform statutory
functions;
(B) any records the provider or person is required
to maintain;
(C) any records necessary to verify items or services
furnished and delivered under Medicaid, any other HHS program, or
any state health care program to determine whether payment for those
items or services is due or was properly made; or
(D) information that includes, without limitation:
(i) clinical patient records;
(ii) other records pertaining to the patient;
(iii) any other records of services provided to Medicaid
or other HHS program recipients and payments made for those services;
(iv) documents related to diagnosis, treatment, service,
lab results, charting, billing records, invoices, documentation of
delivery of items, equipment, or supplies, and radiographs, and all
requirements of Subchapter G, Division 2, of this chapter (relating
to Grounds for Enforcement);
(v) business and accounting records with backup support
documentation, statistical documentation, computer records and data,
patient sign-in sheets, and schedules; or
(vi) any records necessary to fulfill its duty under
the Improper Payments Information Act of 2002, Public Law 107-300,
116 Stat. 2350 (November 26, 2002) requiring state agencies take action
to reduce improper payments. The term "improper payment" means any
payment that should not have been made or that was made in an incorrect
amount (including overpayments and underpayments) under statutory,
contractual, administrative, or other legally applicable requirements,
including any payment to an ineligible recipient, any payment for
an ineligible service, any duplicate payment, any payment for services
not received, or any payment that does not account for credit for
applicable discounts.
(p) A facility that uses an electronic clinical record
system and electronic submissions must comply with this subsection.
(1) A nursing facility that elects to submit electronic
or digital signatures on MDS assessments is required to have a policy
in effect on the date of transmission that ensures it has proper security
measures to protect against the use of an electronic or digital signature
by anyone other than the individual to whom the electronic or digital
signature belongs. The policy must also ensure that clinical records
are made available to the OIG and others who are authorized by law.
(2) In order to receive Medicaid reimbursement, a nursing
facility that utilizes a clinical record system that is entirely electronic
must maintain a hard copy of all MDS assessments in the recipient's
clinical record. The hard copy of an MDS assessment must include the
signatures, title, and date of all individuals completing the MDS.
(q) The OIG conducts a reconsideration review upon
receipt of a written request for reconsideration.
(1) The reconsideration request must be sent in the
form of a letter. The letter must describe in detail the reason a
reconsideration review is requested for each specified assessment
error. A copy of each signed affidavit executed during the unannounced
on-site review for which reconsideration is requested must be attached
to the letter. The reconsideration request must be submitted in the
order outlined in the reconsideration request requirements provided
to the nursing facility staff during the exit conference and must
include all of the information required for a reconsideration request.
(2) The reconsideration request must be mailed to the
OIG Utilization Review unit at the address indicated on the exit documentation
provided to facility staff at the exit conference.
(A) The reconsideration request must be postmarked
on or before the 15th calendar day after the date of the exit conference,
provided, however, that if the 15th calendar day falls on a Sunday
or national holiday as defined in Texas Government Code §662.003(a),
the request must be postmarked on the next following business day.
(B) A reconsideration request that does not meet the
requirements of this paragraph is not granted.
(3) An MDS assessment error that is not identified
in the request is not reconsidered.
(4) A nursing facility may submit additional clinical
records along with a timely request for reconsideration review. Any
such additional records must be accompanied by a notarized Fact and
Records Affidavit that properly authenticates the documents as true
and correct duplicates of business records pursuant to TEX. R. EVID.
803(6) and TEX. R. EVID. 902(10). Additionally, the Fact Affidavit
must specify: why the records were not produced during the unannounced
on-site review, when the records were obtained, where the records
were located, who located the records, and the circumstances under
which the records were obtained. If recipient medical record documentation
that was not provided during the unannounced on-site review is submitted
for reconsideration, the weight to be given any supplemental documentation
remains within the discretion of the reviewer.
(5) If the reconsideration review establishes that
the OIG has changed an MDS RUG-III group in error, the OIG directs
the Texas Medicaid claims administrator to correct the error retroactively.
(6) If the provider disagrees with the reconsideration
determination, the provider may request a formal appeal as described
in Chapter 357, Subchapter I of this title (relating to Hearings Under
the Administrative Procedure Act).
(7) The RUG-III group and the associated per diem rate
specified in the reconsideration determination remain in effect during
the formal appeal process.
(r) The OIG recovers overpayments based on unannounced
on-site review findings associated with an administrative or assessment
error in accordance with this subsection.
(1) An administrative error occurs if a requirement
in subsections (c) and (d) of this section are not met, or the Long-Term
Care Medicaid Information Section or Basic Tracking Form is not made
available to the OIG during regular business hours of the unannounced
on-site review period and prior to the exit conference.
(A) If the unannounced on-site review period is more
than one day, the nursing facility must provide the requested information
to the OIG reviewer by the end of the day information is requested,
during regular business hours.
(B) If a facility cannot produce or make available
the requested information, the facility must provide a written statement
explaining why the information cannot be provided as requested. The
submission of a written statement does not negate the OIG's authority
to take enforcement action under Subchapter G of this chapter.
(C) An administrative error may be reconsidered as
described in subsection (q) of this section.
(2) An assessment error is a RUG reclassification resulting
in an overpayment or underpayment of an MDS assessment claim(s) identified
during a utilization review of a facility.
Cont'd... |
