Opinion ID: 4514777
Heading Depth: 3
Heading Rank: 2

Heading: Attachment 4.19-A, Section IV

Text: ¶56. The DOM refers to the administrative hearing officer’s report and recommendation, which was adopted in toto in the DOM’s Lump Sum Settlement, to argue that subsection E 26 of Section IV “only appl[ies] when DOM discovers errors on the part of DOM or a provider concerning DOM’s documents.” This conclusion is clearly erroneous. ¶57. The language relied upon by the hearing officer and the DOM is not in subsection E of Attachment 4.19-A, Section IV, which provides, Overpayments as a result of an error or misrepresentation will be reimbursable to Medicaid within sixty days of the date of the notification to the Provider of the amount due. Underpayments, likewise determined, will be reimbursable to the Provider. ¶58. In fact, the location of subsection E on page 4 of Attachment 4.19-A-immediately following subsections B (Common Audit Program), C (Other Hospital Audits) and D (Retention), clearly indicates that subsection E (Overpayments/Underpayments) applies to both the common audit program and other hospital audits. As a result, subsection E’s requirement for the DOM to reimburse providers for underpayments applies to both field audits under subsection B and other hospital audits under subsection C. Nothing in subsection E limits the DOM’s ability to correct errors that result in underpayments to hospitals. Instead, it logically provides that “underpayments, likewise determined, will be reimbursable to the Provider.” ¶59. Also, both the DOM and the hearing officer took the position that subsection E “only appl[ies] when DOM discovers errors on the part of DOM or a provider concerning DOM’s documents.” Subsection E does not support the conclusion that CMMC may not appeal the errors in issue here. This is because the DOM’s retro-rate calculation at issue is one of the “DOM’s documents,” and the errors appealed were errors “on the part of DOM.” The specific “DOM document” at issue is entitled “Central MS Medical Center Computation of 27 FY 2001 Rate” and was attached to the lump sum settlement. The “DOM error” at issue is the use of incorrect data in the retro-rate calculation. Thus, the errors appealed by CMMC were “on the part of DOM . . . concerning DOM’s documents.” ¶60. Finally, the DOM argues that “nothing in this provision authorizes DOM to audit or correct the NPR, which is prohibited by Section IV-B.” This is simply wrong; there is no such prohibition. CMMC did not ask the DOM to change the Medicare NPR. The Medicare NPR, which is used to set Medicare rates, will remain unchanged. But, the data used in the Medicaid rate calculation will be corrected. There is no need to amend or change the Medicare NPR for the DOM to use correct data. The DOM only needs to insert the correct data into the Medicaid rate calculation. This correct data was provided to the DOM in 2001 in the Amended Medicaid Cost Report and again through undisputed testimony and documentary evidence at the administrative hearing.