5124.193 Exception reviews of resident assessment data.

(A) The department of developmental disabilities may, pursuant to rules authorized by this section, conduct an exception review of resident assessment data submitted by an ICF/IID provider under section 5124.191 of the Revised Code. The department may conduct an exception review based on the findings of a medicaid certification survey conducted by the department of health, a risk analysis, or prior performance of the provider.

Exception reviews shall be conducted at the ICF/IID by appropriate health professionals under contract with or employed by the department. The professionals may review resident assessment forms and supporting documentation, conduct interviews, and observe residents to identify any patterns or trends of inaccurate resident assessments and resulting inaccurate case-mix scores.

(B) If an exception review is conducted before the effective date of an ICF/IID's rate for direct care costs that is based on the resident assessment data being reviewed and the review results in findings that exceed tolerance levels specified in the rules authorized by this section, the department, in accordance with the rules authorized by this section, may use the findings to redetermine individual resident case-mix scores, the ICF/IID's case-mix score for the quarter, and the ICF/IID's annual average case-mix score. The department may use the ICF/IID's redetermined quarterly and annual average case-mix scores to determine the ICF/IID's rate for direct care costs for the appropriate calendar quarter or quarters.

(C) The department shall prepare a written summary of any exception review finding that is made after the effective date of an ICF/IID's rate for direct care costs that is based on the resident assessment data that was reviewed. Where the provider is pursuing judicial or administrative remedies in good faith regarding the finding, the department shall not withhold from the provider's current payments any amounts the department claims to be due from the provider pursuant to section 5124.41 of the Revised Code.

(D)

(1) The director of developmental disabilities shall adopt rules under section 5124.03 of the Revised Code as necessary to implement this section. The rules shall establish an exception review program that does all of the following:

(a) Requires each exception review to comply with Title XIX;

(b) Requires a written summary for each exception review that states whether resident assessment forms have been completed accurately;

(c) Prohibits each health professional who conducts an exception review from doing either of the following:

(i) During the period of the professional's contract or employment with the department, having or being committed to acquire any direct or indirect financial interest in the ownership, financing, or operation of ICFs/IID in this state;

(ii) Reviewing any provider that has been a client of the professional.

(2) For the purposes of division (D)(1)(c)(i) of this section, employment of a member of a health professional's family by an ICF/IID that the professional does not review does not constitute a direct or indirect financial interest in the ownership, financing, or operation of the ICF/IID.

History. Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.