5165.193 Exception review of assessment data.

(A) The department of medicaid may, pursuant to rules authorized by this section, conduct an exception review of resident assessment data submitted by a nursing facility provider under section 5165.191 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 nursing facility 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 a nursing facility'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 those rules, may use the findings to redetermine individual resident case-mix scores, the nursing facility's case-mix score for the quarter, and the nursing facility's annual average case-mix score. The department may use the nursing facility's redetermined quarterly and annual average case-mix scores to determine the nursing facility'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 a nursing facility'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 5165.41 of the Revised Code.

(D)

(1) The medicaid director shall adopt rules under section 5165.02 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 XVIII and 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 nursing facilities 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 a nursing facility that the professional does not review does not constitute a direct or indirect financial interest in the ownership, financing, or operation of the nursing facility.

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