Ohio Admin. Code 4123-6-45 - Audit of providers' patient and billing related records
(A) Providers'
patient and billing related records, including but not limited to those records
described in rule 4123-6-45.1 of the Administrative Code, may be reviewed by
the bureau or the MCO to ensure workers are receiving proper and necessary
medical care, and to ensure compliance with the bureau's statutes, rules,
policies, and procedures.
(1) Based on
division (B)(16)(c)
(B)(15)(c) of section
4121.121
of the Revised Code, provider records may be reviewed before, during, or after
the delivery of services. Reviews may be random, with no unreasonable
infringement of provider rights, or may be for cause. Reviews may include the
utilization of statistical sampling methodologies and projections based upon
sample findings. Records reviews may be conducted at or away from the
provider's place of business.
(2)
Based on division (B)(16)(c)
(B)(15)(c) of section
4121.121
of the Revised Code, legible copies of providers' records may be requested.
Providers shall furnish copies of the requested records within thirty calendar
days of receipt of the request. The bureau shall establish a schedule for
payment of reasonable costs for copying records, which shall be published in
the health care provider billing and reimbursement manual.
(3) Original records shall not be removed
from the provider's premises, except upon court order or subpoena issued by the
bureau pursuant to section
4121.15
or
4123.08
of the Revised Code.
(B)
Upon any finding of improper or unnecessary medical care, the administrator
shall, if requested by the provider, appoint a subcommittee of the
stakeholders' health care quality assurance advisory committee to review and
advise the administrator as provided in paragraph (F) of rule
4123-6-22
of the Administrative Code. The administrator may sanction, suspend, or exclude
a health care provider from participation in the workers' compensation system
based on rule
4123-6-17
of the Administrative Code.
(C) The
bureau or the MCO may deny payment for services or declare as overpaid previous
payments to providers who fail to provide records or access to records to
either the bureau or the MCO. The bureau may decertify a health care provider
that fails to provide records requested pursuant to Chapters 2913., 4121., and
4123. of the Revised Code.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Prior Effective Dates: 02/12/1997, 01/15/1999, 11/13/2015
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(A) Providers' patient and billing related records, including but not limited to those records described in rule 4123-6-45.1 of the Administrative Code, may be reviewed by the bureau or the MCO to ensure workers are receiving proper and necessary medical care, and to ensure compliance with the bureau's statutes, rules, policies, and procedures.
(1) Based on division (B)(16)(c) (B)(15)(c) of section 4121.121 of the Revised Code, provider records may be reviewed before, during, or after the delivery of services. Reviews may be random, with no unreasonable infringement of provider rights, or may be for cause. Reviews may include the utilization of statistical sampling methodologies and projections based upon sample findings. Records reviews may be conducted at or away from the provider 's place of business.
(2) Based on division (B)(16)(c) (B)(15)(c) of section 4121.121 of the Revised Code, legible copies of providers' records may be requested. Providers shall furnish copies of the requested records within thirty calendar days of receipt of the request. The bureau shall establish a schedule for payment of reasonable costs for copying records, which shall be published in the health care provider billing and reimbursement manual.
(3) Original records shall not be removed from the provider 's premises, except upon court order or subpoena issued by the bureau pursuant to section 4121.15 or 4123.08 of the Revised Code.
(B) Upon any finding of improper or unnecessary medical care, the administrator shall, if requested by the provider , appoint a subcommittee of the stakeholders' health care quality assurance advisory committee to review and advise the administrator as provided in paragraph (F) of rule 4123-6-22 of the Administrative Code. The administrator may sanction, suspend, or exclude a health care provider from participation in the workers' compensation system based on rule 4123-6-17 of the Administrative Code.
(C) The bureau or the MCO may deny payment for services or declare as overpaid previous payments to providers who fail to provide records or access to records to either the bureau or the MCO . The bureau may decertify a health care provider that fails to provide records requested pursuant to Chapters 2913., 4121., and 4123. of the Revised Code.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441
Prior Effective Dates: 02/12/1997, 01/15/1999, 11/13/2015