Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 125 - HOSPITAL SERVICES › Section 410-125-1060 - Fiscal Audits

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Stat. Auth.: ORS
				  413.042
Stats. Implemented: ORS
				  414.065