Chapter 5160-57 Medicaid Provider Incentive Program
(A) The medicaid provider incentive program (MPIP) is Ohio's program implementing section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5, and the published regulations in 42 C.F.R. Part 495. Certain medicaid eligible professionals and hospitals are eligible to participate in MPIP. Funding for this program ends in 2021.
(B) An eligible professional participating in Ohio's MPIP program is a provider that meets eligibility requirements in 42 C.F.R. 495.304 (as in effect on October 1, 2018) and practices within his or her scope of practice as recognized under Ohio law for each type of professional. In addition, an advanced practice registered nurse (APRN) defined in rule 5160-4-04 of the Administrative Code with an appropriate scope of practice will be considered as an eligible provider for Ohio's MPIP program.
(C) Medicaid eligible hospitals participating in Ohio's MPIP program are subject to the program eligibility rules and regulations published in 42 C.F.R. Part 495 (as in effect on October 1, 2018).
(D) To be eligible for a year of participation in MPIP, each eligible professional and hospital must:
(1) Be an enrolled Ohio medicaid provider with an active Ohio medicaid provider agreement;
(2) Except for eligible hospitals, not have received an electronic health record (EHR) incentive payment within the current payment year from another state, MPIP, or the medicare EHR incentive payment program;
(3) Not have a current sanction or exclusion identified at the United States department of health and human services, office of inspector general, list of excluded individuals and entities, or the Ohio medicaid list of excluded providers.
(E) Patient volume requirements.
(1) Eligible professionals and hospitals participating in MPIP must meet annual patient volume requirements in accordance with 42 C.F.R. 495.304 (as in effect on October 1, 2018) with the exception of children's hospitals;
(2) Patient volume is calculated in accordance with the patient encounter methodology defined in 42 C.F.R. 495.306(c) (as in effect on October 1, 2018);
(F) Group practices or clinics patient volume proxy.
(1) A group practice or clinic will be permitted to calculate patient volume at the group practice or clinic level, but only in accordance with all of the limitations defined in 42 C.F.R. 495.306(h) (as in effect on October 1, 2018).
(2) Each group practice or clinic must confirm in writing and provide evidence of consent, in a manner specified by the Ohio department of medicaid (ODM) on the ODM website, www.medicaid.ohio.gov, from each eligible professional in the group practice or clinic that the eligible professional is consenting to one of the following:
(a) Attesting as a member of the group practice or clinic and permitting the group practice or clinic to use his or her encounters in the group practice or clinic patient volume proxy calculation; or
(b) Not attesting as a member of the group practice or clinic but will permit the group practice or clinic to use his or her encounters in the group practice or clinic patient volume proxy calculation.
(3) If an eligible professional is not attesting as a member of a group practice or clinic but will permit a group practice or clinic to use his or her encounters in the patient volume proxy calculation for the group practice or clinic, the non-participating eligible professional cannot use those encounters toward his or her individual patient volume calculation.
(4) If any eligible professional within the group practice or clinic does not provide written consent for the group practice or clinic to use his or her encounters in the patient volume proxy calculation for the group practice or clinic, the group practice or clinic is precluded from using a group practice or clinic patient volume proxy.
(5) Supporting documentation must be provided for processing through the MPIP system of the attested patient volume proxy and include the medicaid encounters, total encounters, name and medicaid ID of all medicaid practitioners used in the group practice or clinic patient volume proxy calculation. This information shall be provided in a manner specified by ODM.
(6) Eligible professionals must be employed by the group practice or clinic at the time of attestation in order to use the group practice's or clinic's patient volume proxy.
(1) Encounters are defined in accordance with 42 C.F.R. 495.306(e) (as in effect October 1, 2018).
(2) "Out-of-state encounters" are services rendered by an eligible professional or hospital to a non-Ohio resident and may be used for calculating patient volume.
(a) If out-of-state medicaid encounters are included in the numerator of the calculation to determine patient volume, all out-of-state encounters for the same representative period should be included in the denominator.
(b) Eligible professionals and eligible hospitals are required to provide documentation to support the use of out-of-state encounters and must report out-of-state encounters from each state separately through the MPIP system, in a manner specified by ODM.
(H) Meaningful use (MU).
(1) Eligible professionals and hospitals must:
(a) Meet all activities required to receive an incentive payment in accordance with 42 C.F.R. 495.314 (as in effect on October 1, 2018), in addition to all program eligibility requirements.
(b) Report which certified EHR technology they have adopted, implemented or upgraded to by providing supporting documentation through the MPIP system at the time of registration and attestation, in a manner specified by ODM.
(c) Demonstrate that meaningful use objectives and measures are met, in accordance with 42 C.F.R. 495.40 (as in effect on October 1, 2018).
(2) Demonstration of MU is subject to review by both ODM and the centers for medicare and medicaid services (CMS).
(3) Dual eligible hospitals meeting MU criteria for the medicare EHR incentive program will be deemed meaningful users for MPIP, but will be required to meet MPIP program eligibility requirements.
(I) Incentive payments.
(1) MPIP incentive payments are calculated in accordance with 42 C.F.R. 495.310 and 42 C.F.R. 495.312 (as in effect on October 1, 2018). Payment will be disbursed to the payee tax identification number selected at the time of attestation.
(2) Eligible professionals and hospitals must meet all requirements set forth in this rule to be eligible for payment.
(3) Eligible professionals may reassign incentive payments in accordance with 42 C.F.R. 495.60(f) (as in effect on October 1, 2018) and other applicable federal and state medicaid laws, rules, and regulations.
(a) The employer or entity for which payment is reassigned must be an Ohio medicaid provider with an active Ohio medicaid provider agreement.
(b) In cases where eligible professionals are associated with more than one practice, the eligible professional must select one tax identification number to receive any applicable EHR incentive payment.
(J) Eligible hospital incentive payments.
(1) All data used to calculate the hospital EHR incentive payment amount must be provided through the MPIP system at the time of the eligible hospital's application and attestation.
(2) All eligible hospital calculations of the aggregate EHR hospital incentive payment made at the time of MPIP application are subject to review and may be adjusted based on review findings.
(3) An eligible hospital may be paid up to one hundred per cent of the calculated aggregate EHR incentive amount over a four-year period, if it meets all MPIP eligibility requirements: forty per cent in year one; thirty per cent in year two; twenty per cent in year three; and ten per cent in year four.
(4) An eligible hospital may not alter or modify data elements used to calculate the hospital EHR incentive payment after MPIP has processed an application for payment and payment has been disbursed for the payment year.
(K) Offsets, adjustments and recoupment of payment.
(1) MPIP payments are subject to offsets, adjustments and recoupments. These and other collection methods will be applied to the medicaid EHR incentive payments to reimburse or pay for medicaid overpayments, fines, penalties, or other debts owed by the provider or its assignee(s) to ODM, Ohio county or local governments, the United States department of health and human services, or any other federal agency.
(2) ODM will identify and recoup overpayments made under the incentive program that result from incorrect or fraudulent attestations, quality measures, cost data, patient data, or any other submission required to establish eligibility or qualify for a payment.
(3) Eligible professionals and eligible hospitals must report any suspected overpayments of an incentive payment to ODM within sixty days of its discovery.
(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.
Five Year Review (FYR) Dates: 8/16/2019 and 11/09/2024
Promulgated Under: 119.03
Statutory Authority: 5162.02, 5164.93
Rule Amplifies: 5164.93
Prior Effective Dates: 1/1/2012, 9/10/2012, 10/1/2013