All skilled nursing facility (SNF) administrators should be aware of the state of Ohio Department of Medicaid (ODM) adjudication process, but many may not know that the findings of the state’s audit can – and should be – refuted.

ODM has launched several new initiatives recently, including the establishment of the Ohio Department of Medicaid Program Integrity Group (PIG) to identify instances of fraud, waste and abuse in Ohio’s Medicaid programs. In addition to promoting effective program management and ongoing monitoring, PIG is also charged with the identification and recoupment of improper Medicaid payments and prosecution of providers where evidence of fraud exists.

The Ohio Medicaid Provider Agreement holds SNF operators accountable for maintaining records for a period of seven years to support claims submitted for payment. SNFs are subject to review by the ODM Program Integrity Bureau for open cost report years and upon change in ownership (CHOW). Currently, the state is finalizing the reviews for State Fiscal Year (SFY) 2011 and is expected to issue the reports for SFY2012 by the end of March 2017. 

How the ODM Medicaid Adjudication Process Works—and What it Means for SNFs

Post-payment reviews are conducted utilizing advanced analytics to mine existing data from the Medicaid Information Technology System (MITS), Ohio Benefits (OB) and/or Client Registry Information System Enhanced (CRIS-E) for indications of improper payment or fraud based on edibility, dates of service and patient liability variances. A Proposed Adjudication Order (PAO) is then sent to the provider requesting recoupment of improper payments. This order is accompanied by a summary of each claim that was reviewed in association with the adjudication process. The facility has 30 days to respond and/or appeal the findings of the audit.

At Richter Healthcare Consultants, we have seen Medicaid adjudication orders demanding recoupment of more than $500,000. Beyond significantly affecting cash flow, recoupments of this size could impede a facility’s ability to operate within budget for an extended period of time. CHOWs can be further complicated by the potential liabilities related to the adjudication process. That process can also potentially impede the outgoing operator’s ability to access records required to support the claims and appeal the audit findings.

Richter Healthcare Consultants understands the serious impact that adjudication orders can have on SNFs, and we can help. Our dedicated Medicaid consultants have many years of experience as case workers and/or supervisors working with SNF providers of all sizes and scopes. Their extensive knowledge of eligibility and billing processes informs their ability to successfully appeal adjudication orders for our clients. In one recent case, their work saved a Richter Healthcare Consultant client over $2,000,000. That bears repeating…$2 million saved for just one client.

Contact Richter Healthcare Consultants

If you have received a Medicaid PAO from the state of Ohio, don’t just accept the state’s findings—please call Richter Healthcare Consultants at 866-806-0799 to schedule a free consultation. Our Medicaid team has saved our clients millions of dollars already—put us to work for you.

Candace Jones is a Senior Consultant with Richter Healthcare Consultants.