5101:3-57-04 Medicaid provider incentive program (MPIP): program integrity and provider appeals.

(A) Program integrity.

(1) MPIP legal notice.

(a) All eligible professionals and eligible hospitals submitting an application to receive an MPIP payment are required to sign the MPIP legal notice before confirming and submitting their application.

(b) All program applicants are bound by the requirements of the MPIP legal notice.

(2) Eligible professional and eligible hospital MPIP applications and attestations are subject to verification by the Ohio department of medicaid (ODM).

(3) For any given payment year an eligible professional and eligible hospital must register for MPIP by the end of the calendar year (CY) for an eligible professional and federal fiscal year (FFY) for an eligible hospital.

(4) An eligible professional and eligible hospital will have sixty days after the end of the CY for an eligible professional and FFY for and eligible hospital to complete attestation via the MPIP system for a given payment year.

(5) Post payment audits and record retention.

(a) An eligible professional's and eligible hospital's MPIP application and attestation are subject to a post payment audit.

(b) ODM or its designee, the state auditor's office, the state attorney general's office and the federal centers for medicare and medicaid services (CMS) may conduct reviews and audits of MPIP applications for the purpose of determining compliance with the requirements of this chapter as well as with applicable state and federal requirements.

(c) Audits and reviews may be conducted on-site as determined necessary based on periodic analysis of medical, financial, and other information.

(d) Records stored electronically must be produced at the eligible professional's or eligible hospital's expense, upon request, in the format specified by ODM.

(e) All records must be maintained for a minimum of seven years following the last day of the CY for eligible professionals or FFY for eligible hospitals in which payment related to the attestation has been received, or in the event that the eligible professional or eligible hospital has been notified that state or federal authorities have commenced an audit or investigation of their MPIP application, until such time as the matter under audit, appeal or investigation has been resolved.

(f) An eligible professional and eligible hospital must comply with all audit recoveries.

(6) Fraud, waste, and abuse.

(a) Suspicion or detection of fraud and abuse by ODM will be referred to the medicaid fraud control unit (MFCU) in the office of the attorney general (AG). Referrals to the MFCU will be investigated for prosecutorial merit.

(b) Substantiated cases of fraud and abuse will be prosecuted according to federal and state regulations.

(B) Provider appeals.

(1) An eligible professional or eligible hospital may appeal the following issues related to MPIP, by first requesting an informal review:

(a) Incentive payment amounts.

(b) Provider eligibility determinations (i.e. patient volume, hospital-based).

(c) Demonstration of adoption, implementation, or upgrade, and meaningful use eligibility.

(2) Appeals filed after the deadlines specified in paragraphs (B)(3)(a) and (B)(4)(a) of this rule, will be dismissed without the ability to refile. If the deadline falls on a saturday, sunday, state or federal holiday, the period for requesting an appeal will be extended to the next business day.

(3) Informal review.

(a) If the MPIP system has made a preliminary determination that may be adverse regarding the incentive payment application of an eligible professional or eligible hospital, the eligible professional or eligible hospital may request an informal review of the preliminary determination via the MPIP system, within fifteen calendar days of notification of an adverse preliminary determination.

(b) A request for informal review shall be made via the MPIP system and may include supporting documentation to support the request.

(c) An eligible professional or eligible hospital will be notified of the informal review decision via email and will be advised to log into the MPIP system to see the details of the review decision.

(d) An eligible professional or eligible hospital may withdraw the request for an informal review via the MPIP system, without reason, at any time, after the initial filing and before an informal review decision is issued.

(4) Request for reconsideration.

(a) If the informal review upholds the preliminary adverse determination and the eligible professional or eligible hospital does not agree with the informal review decision, the eligible professional or eligible hospital may submit a written request for reconsideration no later than fifteen calendar days after the date of notification of determination via the MPIP system.

(b) The request for reconsideration shall be initiated via the MPIP system and must include a written and signed letter from the eligible professional or eligible hospital containing the following information:

(i) Clear identification of the affected eligible professional or eligible hospital;

(ii) The proposed action being contested;

(iii) The basis for requesting reconsideration; and

(iv) Supporting documentation being submitted.

(c) The written request for reconsideration must be signed, dated, include any supporting documentation and must be uploaded via the MPIP system.

(d) An eligible professional or eligible hospital will be notified in writing, by certified mail, of the reconsideration decision.

(5) In accordance with Chapter 2505. of the Revised Code, an eligible professional or eligible hospital may appeal the reconsideration decision by filing a notice of appeal with the court of common pleas of Franklin county. The notice shall identify the decision being appealed and the specific grounds for the appeal. The notice of appeal shall be filed not later than fifteen days after the department mails its notice of the reconsideration decision. A copy of the notice of appeal shall be filed with the department not later than three days after the notice is filed with the court.

Effective: 10/01/2013
R.C. 119.032 review dates: 08/05/2018
Promulgated Under: 119.03
Statutory Authority: 5111.0215
Rule Amplifies: 5111.0215
Prior Effective Dates: 1/1/12, 09/10/2012