Reimbursement

Reimbursement A. Participating Mississippi nursing facilities must prepare and submit a Medicaid cost report for reimbursement. 1. All cost reports are due by the end of the fifth (5th) calendar month following the reporting period. 2. Failure to file a cost report by the due date or the extended due date will result in a penalty of fifty dollars ($50.00) per day and may result in the termination of the provider agreement. B. The Division of Medicaid uses a prospective method of reimbursement. 1. The rates are calculated from cost reports and resident case-mix assessment data. 2. Standard rates are calculated annually with an effective date of January first (1st). 3. Rates are adjusted quarterly based on changes in the case-mix of the facility. 4. In no case may the reimbursement rate for services exceed an individual nursing facility’s customary charges to the general public for such services in the aggregate, except for those public nursing facilities rendering such services free of charge or at a nominal charge. 5. Prospective rates may be adjusted by the Division of Medicaid pursuant to changes in federal and/or state laws or regulations. 6. Prospective rates may be adjusted by the Division of Medicaid based on revisions to allowable costs or case-mix scores or to correct errors. a) These revisions may result from amended cost reports, field visit reviews, audits or other corrections. b) Facilities are notified in writing of amounts due to or from the Division of Medicaid as a result of these adjustments. c) There is no time limit for requesting settlement of these amounts. C. The Division of Medicaid conducts periodic cost report financial reviews of selected nursing facilities to verify the accuracy and reasonableness of the financial and statistical information contained in the Medicaid cost reports. Adjustments will be made as necessary to the cost reports based on the results of the reviews. D. Each nursing facility that is participating in the Medicaid program must keep and maintain books, documents and other records as prescribed by the Division of Medicaid in substantiation of its cost reports for a period of three (3) years after the date of submission to the Division of Medicaid of an original cost report, or three (3) years after the date of submission to the Division of Medicaid of an amended cost report. 1. Providers who are required to pay assessments must keep and preserve books and records as necessary to determine the amount of the assessments for which it is liable for no less than five (5) years. 2. Providers must maintain adequate documentation, including, but not limited to, financial records and statistical data, for proper determination of costs payable under the Medicaid program. a) The cost report must be based on the documentation maintained by the nursing facility. b) All non-governmental nursing facilities must file cost reports based on the accrual method of accounting. c) Governmental nursing facilities have the option to use the cash basis of accounting for reporting. 3. Documentation of financial and statistical data must be maintained in a manner consistent from one (1) period to another and must be current, accurate and in sufficient detail to support costs contained in the cost report. 4. Providers must make available to the Division of Medicaid all documentation that substantiates the information included in the nursing facility cost report for the purpose of determining compliance with Medicaid rules. a) These records must be made available as requested by the Division of Medicaid. b) All documentation which substantiates the information included in the nursing facility cost report, including any documentation relating to home office and/or management company costs must be made available to the Division of Medicaid reviewers as requested by the Division of Medicaid. E. The Division of Medicaid reimburses for the day of admission to a nursing facility. 1. The day of discharge is not reimbursed by the Division of Medicaid unless it is the same day as the date of admission. 2. Nursing facilities cannot bill the resident or responsible party for the day of discharge. F. The Division of Medicaid reimburses for home/therapeutic and inpatient hospital temporary leave. 1. Home/therapeutic temporary leave is limited to forty-two (42) days per year in addition to holidays listed in Miss. Admin. Code Part 207, Rule 2.8. Reimbursement is limited to fifteen (15) consecutive days per leave period. 2. Inpatient hospital temporary leave days are not limited except for reimbursement of a maximum of fifteen (15) consecutive days per leave period. 3. If the resident has utilized the fifteen (15) consecutive day maximum, the resident must return to the facility for twenty-four (24) consecutive hours before the nursing facility can be reimbursed for a new temporary leave period. G. The Division of Medicaid does not reimburse for the following instances: 1. Nursing facilities which bill the Division of Medicaid for fifteen (15) consecutive days of home/therapeutic or inpatient hospital temporary leave, discharge the resident from the nursing facility, and subsequently refuse to readmit the resident under the nursing facility’s resident return policy when a bed is available. 2. Inpatient hospital temporary leave for days when a resident is transferred to a Medicare skilled nursing facility (SNF) or a swing bed after an acute care hospitalization. 3. Medicaid billing of home/therapeutic or inpatient hospital temporary leave for more than fifteen (15) consecutive days. H. Nursing facilities must bill the appropriate day code as follows: 1. For a resident who has a home/therapeutic temporary leave bill a home/therapeutic leave day code beginning the calendar day the resident: a) Leaves the facility for eight (8) consecutive hours or more during the day excluding: 1) Dialysis, 2) Chemotherapy, 3) Physical therapy, 4) Speech therapy, 5) Occupational therapy, or 6) Medical treatments that occur two (2) or more days per week, b) Is out of the facility at twelve midnight (12 a.m.), c) Is out of the facility for a hospital observation stay of eight (8) or more consecutive hours, or d) Returns from a therapeutic leave if the resident was out of the facility for eight (8) or more consecutive hours on the return day except for the day of return after a hospital observation stay of eight (8) or more consecutive hours. 2. For a resident who has an inpatient hospital temporary leave, bill an inpatient hospital leave day code beginning the calendar day the resident is admitted to an inpatient hospital for continuous acute care. 3. Bill a room and board day code: a) If the resident does not meet the criteria for either a home/therapeutic or inpatient hospital temporary leave, b) If the resident receives: 1) Dialysis, 2) Chemotherapy, 3) Physical therapy, 4) Speech therapy, 5) Occupational therapy, or 6) Medical treatments that occur two (2) or more days per week. c) The day the resident returns to the nursing facility from an inpatient hospital acute care stay or a hospital observation stay of eight (8) or more consecutive hours, or d) The day the resident returns to the nursing facility from a home/therapeutic leave if the resident was out of the facility for less than eight (8) consecutive hours. [Refer to Miss. Admin. Code Part 207, Rule 2.5.H.3.c)] I. Nursing facilities are required to maintain complete and accurate room and board and temporary leave records in order to accurately bill the fiscal intermediary. J. Nursing facilities must enter the correct temporary leave, regardless of the resident’s payment source, in the case-mix web portal to match the billing records as specified in Miss. Admin. Code Part 207, Rule 2.5.H.1. or 2. 1. The deadline for entering temporary leave information for the quarter is the fifth (5th) day of the second (2nd) month following the end of the quarter the leave occurred. 2. The case-mix review process includes a review and reconciliation of the facility’s official home/therapeutic and inpatient hospital temporary leave records.