05/31/2017
Ohio Department of Medicaid Restarting Exception Review Process
The Ohio Department of Medicaid (ODM) shared at a meeting on Wednesday May 24 that they intend to restart the nursing facilities exception review process beginning in the next few weeks.
ODM has awarded Myers and Stauffer with the contract to conduct approximately 100 exception reviews in the first year. This contracted vendor will give a two-day notice by calling the facility and following up with an email. One contracted nurse is expected to take one to two days to complete the review, depending on the facility size. The contracted vendor will upload the facility’s MDS data prior to arrival. The review will include record review only; the review will not include resident observations. The facility will receive communication throughout the review and have the opportunity to provide supporting documentation. Upon completion, the facility will know which resident RUG categories were unable to be validated. A summary of the exception review will be sent to the facility within 10 days of the exit. The facility will be able to file a reconsideration within 30 days.
ODM plans to continue to review the OAC 5160-3-43.4 and the ORC 5165.193 as they continue to clarify the review process with the contracted vendor and provide additional specifics to the associations.
LeadingAge Ohio Advocacy in Action
- LeadingAge Ohio advocated to change proposed processes related to how the contractor would validate the RUG categories. This included allowing ADL validation to occur in formats other than an ADL flow sheet.
- LeadingAge Ohio requested clarification on the qualifications and the associations were told the nurse would be AANAC certified.
- LeadingAge Ohio requested that the contracted vendor clearly identify themselves on the call that would be made to the facility two days prior to the review. The contractor will identify themselves as “Myers and Stauffer calling” regarding the facilities exception review; the caller will ask to speak to the Administrator, DON, or ADON. If unable to reach them, the caller will leave a message with the receptionist and obtain the facility’s email address.
- Upon LeadingAge Ohio’s request for transparency and clarification on the sampling process, ODM verified the exception review timing does not correlate with any other initiatives occurring within the state, including the budget process. ODM indicated that it desires a sample of facilities that have had a significant change in their average case mix scores. ODM plans to defer the recommended facility selection to the contracted vendor.
- LeadingAge Ohio asked for further description of the contracted vendor’s resident selection process and the contracted vendor stated it would be a random selection that would include a variety of RUG categories.
- LeadingAge Ohio asked for further clarification on the thresholds that could impact expanded sampling and/or recalculating of facility case mix scores.
Members with questions are encouraged to reach out to Stephanie DeWees, Quality and Regulatory Specialist, at sdewees@leadingageohio.org or Nisha Hammel, Director of Advocacy, at nhammel@leadingageohio.org.