(a) OIG selects nursing facilities for utilization
review by conducting a comprehensive annual review of all facilities,
considering factors such as:
(1) length of time since the last review;
(2) whether the nursing facility has ever been reviewed;
(3) previous review results;
(4) compliance history of the nursing facility;
(5) nursing facilities with claims in high-dollar reimbursement
categories such as rehabilitation, extensive services, and special
care services;
(6) variances in billing patterns;
(7) data analytics indicating potential fraud, waste,
or abuse; and
(8) complaints and referrals.
(b) Onsite Utilization Reviews.
(1) Onsite utilization reviews (onsite reviews) may
be announced or unannounced.
(2) The onsite review period begins when an OIG nurse
reviewer presents an entrance letter to the nursing facility provider
and ends when the nurse reviewer informs the provider that the onsite
review is completed. The onsite review period does not include the
onsite exit conference.
(3) During the onsite review, the nurse reviewer informs
the facility staff which minimum data set (MDS) assessments were selected
for review.
(4) The nursing facility provider must ensure an assigned
staff member knowledgeable of the MDS assessments and clinical records
is available at the facility to the nurse reviewer during the entire
onsite review.
(5) A nursing facility provider must make reasonable
efforts to begin providing requested documents to the nurse reviewer
immediately after entrance to the facility. For records stored on-site,
a nursing facility provider must provide all requested documents to
the nurse reviewer within a reasonable time, not to exceed three hours,
after the nurse reviewer's request for documents and during regular
business hours. If OIG determines the requested records are stored
off-site or otherwise unavailable for immediate retrieval, OIG may
extend the three-hour deadline.
(6) During the onsite review, when the nurse reviewer
identifies a potential MDS assessment error, the nurse reviewer requests
supporting documentation from the assigned nursing facility staff
member.
(7) The nursing facility provider must provide to OIG
all requested documentation, including supporting documentation described
in paragraph (6) of this subsection, in the format requested, during
business hours of the onsite review period and prior to the onsite
exit conference, except when OIG determines that the provider has
made reasonable efforts to provide such documentation during the onsite
review period but has been unable to do so.
(8) If OIG determines that the nursing facility provider
has made reasonable efforts to provide requested documentation during
the onsite review period but has been unable to do so, OIG allows
the provider to provide the requested documentation in the format
and time frame determined by OIG.
(9) When requested, the nursing facility provider must
provide, for each requested record, a signed and notarized OIG-approved
records affidavit that properly authenticates the documents provided
to OIG as business records pursuant to Texas Rules of Evidence Rule
803(6) and Rule 902(10).
(10) If a nursing facility provider does not produce
records requested by the nurse reviewer, the provider must provide
a written statement explaining why the records were not produced.
(11) If a nursing facility provider refuses to provide
a records affidavit, the nursing facility provider must state the
refusal in writing and attach the statement to the records provided
to the nurse reviewer.
(12) Failure to produce requested records and affidavits
may result in an OIG enforcement action under Subchapter G of this
chapter (relating to Administrative Actions and Sanctions).
(c) Desk Utilization Reviews.
(1) For a desk utilization review, OIG sends the nursing
facility provider a written request for records. The written request
for records specifies the date the requested records must be received
by OIG. The written request for records gives the provider 30 calendar
days to provide the requested records to OIG.
(2) The nursing facility provider must provide all
requested records in the format requested, and, when requested, a
signed and notarized OIG-approved records affidavit for each requested
record that properly authenticates the documents as business records
pursuant to Texas Rules of Evidence Rule 803(6) and Rule 902(10) to
OIG by the date specified in the written request for records.
(3) If a nursing facility provider does not produce
the requested records by the date specified in the OIG records request,
the provider must provide a written statement explaining why the records
were not produced.
(4) If a nursing facility provider refuses to provide
a records affidavit, the nursing facility provider must state the
refusal in writing and attach the statement to the records provided
to OIG.
(5) Failure to produce requested records and affidavits
may result in OIG enforcement action under Subchapter G of this chapter
(relating to Administrative Actions and Sanctions).
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