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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-48. MEDICAID PROGRAM: REIMBURSEMENT |
Section 29-4822. COST REPORT, AUDIT, AND RECORD MAINTENANCE
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4822.1All general and specialty hospitals enrolled in the District of Columbia Medicaid program shall meet the applicable cost report, audit and record maintenance requirements, as set forth in Sections 4822 and 4823, as a condition of receipt of Medicaid reimbursement.
4822.2Each hospital shall notify DHCF in writing if the Center for Medicare and Medicaid Services (CMS) extends the submission date for the cost report filed with the Medicare program.
4822.3For purposes of compliance with timeframes established within this section, all references to calendar days exclude any federal and District holidays that occur within that span of time.
4822.4 All references to timeframes for sending or receiving documents shall consider receipt to occur five (5) calendar days from the date on the letter, notice or communication.
4822.5Each in-District general and specialty hospital shall be required to submit to DHCF Form CMS-2552-10, or its successor, issued by CMS, U.S. Department of Health and Human Services (HHS). A valid Form CMS 2252-10 shall include a current Office of Management and Budget (OMB) control number.
4822.6A complete cost report shall consist of a valid Form CMS-2250-10 and all required supplemental documentation, including an Executive Compensation Schedule.
4822.7Each in-District hospital delivering inpatient services, identified at Sections 4800 through 4813; specialty services, identified at Sections 4813 through 4819; and outpatient services, identified at 29 DCMR § 903, shall submit a complete cost report as follows:
(a) Annually, within one hundred fifty (150) calendar days after the close of the hospital’s fiscal year; or
(b) Within ninety (90) calendar days after the close of the hospital’s fiscal year (FY) under the following circumstances:
(1) Upon terminating participation in the District’s Medicaid program;
(2) Upon a change in ownership; or
(3) Upon a change in licensure status.
(c) Specialty hospitals paid transition rates, as described in Subsection 4815.6, shall submit a cost report within ninety (90) calendar days after the close of the hospital’s fiscal year.
4822.8Within thirty (30) calendar days of the date on which the cost report is due, the Department of Health Care Finance (DHCF) shall issue a Notice of Delinquency to a hospital that has not timely submitted its cost report or when a submitted cost report is incomplete. The submission of an incomplete cost report shall be treated as a failure to file a cost report.
4822. 9If a hospital has not submitted a complete cost report within thirty calendar (30) days of the date on the Notice of Delinquency, DHCF shall withhold seventy-five percent (75%) of the hospital’s Medicaid reimbursement for the month in which the cost report is due and any subsequent monthly reimbursement occurring prior to the receipt of a complete cost report. DHCF shall promptly disburse withheld reimbursement upon receipt of a complete cost report.
4822.10DHCF shall provide each hospital with a written summary of its submitted (i.e., unaudited) annual cost report data for the hospital’s FY that ends before October 1 of the previous calendar year. The data shall be used to calculate the hospital’s reimbursement rates for the District’s next FY beginning October 1.
4822.11Each hospital shall have thirty (30) calendar days from the date of the cost report summary to review and certify the accuracy of cost report data, in writing, or to submit a written request for review and correction of the cost report data.
4822.12Each hospital’s cost report shall be deemed complete and validated thirty (30) calendar days after the date of the cost report summary unless the hospital requests a data review and correction or if the hospital does not provide a timely response.
4822.13DHCF’s review of the cost report data shall be:
(a) Limited to the hospital’s allegations that data is incomplete or incorrect;
(b) Supported by documentation submitted by the hospital; and
(c) Solely a data review.
4822.14If the data review for validating the cost report data results in changes to the data used then DHCF shall use the updated data to determine base rates and add on payments for the District’s next fiscal year beginning on October 1.
4822.15Within thirty (30) days of receipt of the hospital’s request, DHCF shall notify the hospital of the results of the data review.
4822.16 A hospital’s request for a cost report data review by DHCF shall not be subject to appeal through the Office of Administrative Hearings (OAH).
4822.17 For a specialty hospital that is paid a transition rate, as described in Subsection 4815.6, DHCF shall conduct a post-audit reconciliation after completion of the first District FY during which the transition rate was used. The reconciliation process shall be intended to evaluate the impact of the transition rates compared to the hospital’s costs for the base year.
4822.18 The process for reconciliation shall only apply to hospitals that are paid transition rates.
4822.19 The process for reconciliation shall be as follows:
(a) Affected hospitals shall submit to DHCF a cost report as described in Subsection 4822.6;
(b) DHCF, or its designee, shall audit the cost report and determine allowable costs by using Worksheet C, or its successor, of the audited cost report (i.e., determine audited CCR amount);
(c) DHCF, or its designee, shall evaluate claims data representing paid hospital stays during the District’s corresponding fiscal year;
(d) Final hospital costs for the District’s corresponding fiscal year shall then be determined by applying the audited CCR amount against the charges from the stays during the District’s corresponding fiscal year;
(e) Based on final costs, a hospital’s base rate for the District’s fiscal year under review shall be adjusted in order to reconcile the difference between costs represented in the transition rate and actual costs calculated from the hospital’s fiscal year stays and audited CCR amount;
(f) A new hospital base rate shall be calculated using the methodology established for each hospital, taking into account the new cost amount. The new rate shall be the base rate, adjusted annually for inflation until the next rebasing period;
(g) The hospital’s stays during the fiscal year under review shall be reprocessed using the new rate, which may result in an overpayment to the hospital or an additional payment to the hospital; and
(h) All claims occurring after FY 2015, but prior to the reconciliation described in Subsections 4822.19(a)-(h), shall be subject to reprocessing. Reprocessing may result in repayment from the hospital or an additional payment to the hospital.
4822.20 DHCF, or its designee, acting on behalf of the District and the U.S. Department of Health and Human Services (HHS), or its designee, shall have the right to conduct audits at any time, upon reasonable notice to the hospital.
4822.21 Each hospital shall maintain sufficient financial records and data to properly determine allowable costs, and shall allow authorized agents of the United States Department of Health and Human Services (HHS) and the District to verify claims and reported costs.
4822.22 For purposes of this rule, an audit shall include a desk or field review or a field or on-site audit.
4822.23 Each hospital shall maintain all of its accounting and related records, including the general ledger and records of original entry, and all transaction documents and statistical data, which shall be considered as permanent records and be retained for a period of not less than six (6) years after the filing of a cost report.
4822.24 Each hospital shall also maintain all related documentation for any audit or appeal that is in progress when the required six (6) year period has tolled until the conclusion of that audit or appeal.
4822.25 Each hospital shall ensure that representatives of the District or federal government have access to any records pertaining to related organizations, as defined in 42 C.F.R § 413.7, including relevant financial records and statistical data to verify costs previously reported to DHCF.