Ohio Code 5165.41 – Redetermination of rates
(A) The department of medicaid shall redetermine a provider‘s medicaid payment rate for a nursing facility using revised information if any of the following results in a determination that the provider received a higher medicaid payment rate for the nursing facility than the provider was entitled to receive:
Terms Used In Ohio Code 5165.41
- Direct care costs: means all of the following costs incurred by a nursing facility:
(1) Costs for registered nurses, licensed practical nurses, and nurse aides employed by the nursing facility;
(2) Costs for direct care staff, administrative nursing staff, medical directors, respiratory therapists, and except as provided in division (O)(8) of this section, other persons holding degrees qualifying them to provide therapy;
(3) Costs of purchased nursing services;
(4) Costs of quality assurance;
(5) Costs of training and staff development, employee benefits, payroll taxes, and workers' compensation premiums or costs for self-insurance claims and related costs as specified in rules adopted under section 5165. See Ohio Code 5165.01
- Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
- Provider: means an operator with a provider agreement. See Ohio Code 5165.01
- state: means the state of Ohio. See Ohio Code 1.59
- State fiscal year: means the fiscal year of this state, as specified in section 9. See Ohio Code 5165.01
(1) The provider properly amends a cost report for the nursing facility under section 5165.107 of the Revised Code;
(2) The department makes a finding based on an audit under section 5165.109 of the Revised Code;
(3) The department makes a finding based on an exception review of resident assessment data conducted under section 5165.193 of the Revised Code after the effective date of the nursing facility’s rate for direct care costs that is based on the resident assessment data;
(4) The department makes a finding based on a post-payment review conducted under section 5165.49 of the Revised Code.
(B) The department shall apply the redetermined rate to the periods when the provider received the incorrect rate to determine the amount of the overpayment. The provider shall refund the amount of the overpayment. The department may charge the provider the following amount of interest from the time the overpayment was made:
(1) If the overpayment resulted from costs reported for calendar year 1993, the interest shall be no greater than one and one-half times the current average bank prime rate.
(2) If the overpayment resulted from costs reported for a subsequent calendar year:
(a) The interest shall be no greater than two times the current average bank prime rate if the overpayment was no more than one per cent of the total medicaid payments to the provider for the state fiscal year for which the overpayment was made.
(b) The interest shall be no greater than two and one-half times the current average bank prime rate if the overpayment was more than one per cent of the total medicaid payments to the provider for the state fiscal year for which the overpayment was made.