Changes to the Medicaid High Cost Outlier Review Process (200506)

FROM: Theodore O. Will, Chief Executive Officer
DATE: Oct 05, 2005
SUBJECT: CHANGES TO THE MEDICAID HIGH COST OUTLIER REVIEW PROCESS
IPRO CONTACTS:

Kathleen M. Fox, RN, Senior Director – Medicaid/State Healthcare Assessment at extension 361 or Doreen Walz, RN, Assistant Director at extension 444

IPRO, at the direction of the New York State Department of Health (DOH) is amending its high cost outlier review process. These changes are being made as a method to streamline the process and will result in quicker payment on a case.

Training on the revised high cost outlier review process was provided in September and the revised process will begin on October 1, 2005. Attachment II outlines the steps that need to be followed to facilitate the IPRO review. To summarize, for discharges on or after October 1, 2005 key changes will include:

• Hospitals will have 60 days to respond to the IPRO chart and itemized bill request (an increase of 30 days).
• DOH determines that hospitals will receive a partial payment of 50% (up to a maximum of $150,000) of the cost outlier payment from DOH at the time the case meets cost outlier criteria. There is no time limit associated with this up-front payment. As long as the case is undergoing cost outlier review at IPRO, DOH will not recover the funds.
• The IPRO processes have been streamlined as follows:
  • The chart, itemized bill and newly developed checklist, which are to be completed and signed by a hospital representative, must be sent to IPRO together.
  • The process of IPRO checking for chart completeness and the issuance of a Documentation Letter has been eliminated. A chart review will be based on submitted documentation and denials can be addressed in the hospital’s response to the Preliminary Denial letter.
  • Technical Denials will be issued when the chart and/or the itemized bill have not been submitted and will be capped at two technical denials per case. The hospital will have six months from the date of the technical denial to rebill the case. If not rebilled during that six months, the case will be closed. The issuance of a second technical denial will close the case.
• From October 1, 2005 to December 31, 2005, when the completed and signed checklist is not received, IPRO will call the facility and indicate that the review will not occur until the checklist is received. Beginning January 1, 2006 when the checklist is not received the chart and itemized bill will be returned to the hospital and if not returned by the hospital within 30 days, a technical denial will be issued.
• At any time during the review process (beginning with the Preliminary Denial to the Final Denial) a hospital may elect to agree with IPRO’s determination(s) and request to have the case closed and reported to DOH for adjudication. This will expedite any additional payment to the hospital and close the case to any further appeals from the hospital.

Attached please find the DOH letter explaining the changes (Attachment I); a description of the IPRO review process to begin on October 1, 2005 (Attachment II); and a copy of the Checklist Letter (Attachment III).

If you have any questions, please call the above contacts.

Attachments:

1. DOH Notification Letter
2. Description of the IPRO review process to begin on October 1, 2005. (Including a restatement of how to prepare the itemized bill and pharmacy charges, New High-Cost Outlier Process.)
3. Checklist Letter

Should you have any questions concerning this memorandum, please feel free to contact Kathleen M. Fox, RN, Senior Director – Medicaid/State Healthcare Assessment, at (516) 326-7767 ext. 361.