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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-28. Cost-Based Clinic (FQHC, OHF, RHC) Services |
5160-28-05.2. Cost-based clinics: prospective payment system (PPS) method for determining OHF payment
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(A) An all-inclusive per-visit payment amount (PVPA) is established for each outpatient health facility (OHF) service provided at an OHF service site.
(1) For every OHF newly enrolled as a medicaid provider, the department sets the PVPA for a service at the average PVPA for all participating OHFs.
(2) After the initial PVPAs are set, each OHF submits an annual cost report in accordance with rule 5160-28-04.2 of the Administrative Code. New PVPAs are established on the basis of the cost report, to which an inflation factor is applied.
(a) The inflation factor is the sum of the following figures:
(i) The actual inflation rate between the midpoint of the cost report year and the midpoint of the following year as established by the United States bureau of labor statistics; and
(ii) An estimated inflation rate from the midpoint of the preceding year to the midpoint of the year for which the PVPA is calculated based upon the preceding twelve-month average.
(b) Unless otherwise specified, an inflation factor is computed from monthly statistical data supplied by the United States bureau of labor statistics for the following cost areas:
(i) Non-physician-level personnel costs (e.g., nurses, administration, legal staff, accounting, management, data services, employee fringe benefits, medical records, operation and maintenance services, housekeeping, laundry);
(ii) Medical supplies countable as a separate expense;
(iii) Non-durable goods (e.g., office supplies, printing);
(iv) Fuel and utilities;
(v) Transportation services;
(vi) Physician-level medical personnel and rehabilitation professionals;
(vii) Insurance; and
(viii) Real estate taxes.
(B) Audits.
(1) The principal objective of an audit is to determine whether payments have been made or will be made in accordance with all applicable regulations, rules, and requirements.
(2) The department conducts two types of audits:
(a) A desk audit of cost reports; and
(b) An on-site (field) audit of a facility.
(3) Each on-site audit must be sufficiently comprehensive in scope to demonstrate, in all material respects, whether the costs reported and submitted by an OHF are true, correct, and representative to the best of the facility's ability.
(4) If reported costs exceed costs established by an on-site audit, then the difference is subject to recovery in full. All amounts owed must be repaid within thirty days after an audit has been made final.
(5) If an OHF fails to retain or provide required financial and statistical records, then it may be required to repay the aggregate difference between its PVPAs for the year in question and the lowest PVPAs for like services established for an OHF of similar size and structure.
(6) No further payment will be made to an OHF that refuses a request for an audit.
(C) Decisions of the department with respect to the establishment or adjustment of a PVPA are not subject to Chapter 119. of the Revised Code.