048-24 Wyo. Code R. §§ 24-16 - Request for TEFRA target rate adjustment

(a) Request for TEFRA target rate adjustment. A provider may request a rate adjustment by mailing a written request to the Department by certified mail within sixty days after the date of the Notice of Medicaid Program Reimbursement provided pursuant to subsection 8(c). The request must include the information included in subparagraphs (i) through (iii). A request for rate adjustment shall be dismissed with : this subsection.not comply with the requirements of this subsection.

(i) The nature of the rate adjustment sought;

(ii) The amount of the requested rate adjustment, the methodology used to calculate the requested rate adjustment, the specific calculation for the requested rate adjustment, and documentation which supports the above; and

(iii) The specific reasons, including references to a applicable federal and State law, that justify the rate adjustment.

(b) Department's responsibilities.

(i) The Department shall acknowledge, in writing, receipt of the request for rate adjustment within fifteen days after receipt;

(ii) The Department may request, in writing, additional information from that provider. The provider must the requested information to the Department, by certified mail, within sixty days after receipt of the request. Failure to timely provide the requested information shall result in the dismissal, with prejudice, of the request for rate adjustment.

(iii) The Department shall review the request for rate adjustment to determine whether the request meets any of the criteria set forth in subsection (c).

(iv) Burden of proof. Except as otherwise provided by these rules, the provider requesting a rate adjustment shall bear the burden of proving by a preponderance of the evidence that it is entitled to a rate adjustment.

(v) Notice of final decision. The Department shall send written notice to the provider, by certified mail, of its final decision within one-hundred eighty days after the receipt of the request for rate adjustment or the receipt of any additional information requested by the Department pursuant to (ii), whichever is later. The provider may request an administrative hearing regarding the decision of the Department pursuant to (g).

(c) Bases for rate adjustment. The Department may grant a request for rate adjustment if the provider demonstrates that:

(i) There has been a significant increase in the acuity of care provided by the hospital since the base year and the failure to make a rate adjustment will result in recipients not having reasonable access to inpatient hospital services of adequate quality;

(ii) Extraordinary circumstances occurring since the base year have caused the provider to incur substantially higher costs;

(iii) There has been an error in the calculation of the provider's TEFRA cost per discharge target amount;

(iv) The provider is rendering atypical services;

(v) The provider is located in an area with a significant change in the Medicaid population during the year;

(vi) The provider is engaged in an approved medical or paramedical education program that has resulted in increased costs;

(vii) For cost reporting periods beginning before October 19 z, the provider is rendering more intensive routine care resulting in a shorter length of stay and higher per unit costs than in comparable hospitals;

(viii) Application of the limit would render a hospital insolvent, thereby depriving the community of essential services (the hospital must have exceeded the limit by more than fifteen percent);

(ix) The provider is newly established home health agency (an agency certified for Medicare less than three full years); or

(x) The provider has labor costs that vary by more than ten percent from the labor costs that were used in promulgating the limits.

(d) In determining whether to grant a rate adjustment pursuant to subsection (c), the Department shall consider:

(i) Whether the provider has demonstrated that its unreimbursed costs are caused by factors generally not shared by other Wyoming hospitals;

(ii) Whether the provider has taken every reasonable step to control costs; and

(iii) Whether the provider's costs may be controlled through good management practices or cost containment measures. In determining whether the providers costs may be so controlled, the Department may consider:

(A) Efforts to reduce or contain employee benefits;

(B) Efforts to consolidate or centralize personnel or departmental functions;

(C) Efforts to review departmental staffing levels and use lesser-skilled employees or reduce full-time equivalent employees, without adversely affecting the quality of patient care;

(D) Efforts to affect physicians order patterns, e.g., through use of drug formularies, standardizing supplies, and reducing unnecessary tests;

(E) Efforts to reduce reliance on agency or registry personnel;

(F) Efforts to expedite billing;

(G) Use of volunteers and fund-raising;

(H) Efforts to control costs;

(I) Efforts to reduce the incidence of employee injuries;

(K) Efforts to reduce employee turnover;

(L) Efforts to improve efficiency through improved scheduling;

(M) Equipment sharing arrangements; and

(N) The use of information or management systems and procedures.

(e) Calculation of rate adjustment. If the Department determines pursuant to subsection (d) that a hospital is entitled to a rate adjustment for one of the reasons specified in subsection (c), the rate adjustment shall be calculated as follows:

(i) The Department shall recalculate the provider's target amount using the rate year for which the rate adjustment was requested, unless the rate adjustment is based on extraordinary circumstances.

(ii) If the rate adjustment is based on extraordinary circumstances, the Department may increase the per discharge ceiling by the amount necessary to meet the Medicaid share of the net additional allowable costs incurred as a result of the extraordinary circumstances.

(f) Effect of rate adjustments.

(i) Rate adjustments resulting from extraordinary circumstances shall be limited to the fiscal period in question.

(ii) Rate adjustments other than adjustments resulting from extraordinary circumstances shall be limited to the fiscal period in question unless the facility shows, for each succeeding rate period, that the conditions which resulted in the rate adjustment still exist.

(g) Administrative hearing. A Provider may request an administrative hearing regarding the final agency decision pursuant to chapter I of these rules by mailing by certified mail or personally delivering a request for hearing to the Department within twenty days after the date the provider receives notice of the final agency decision.

(h) Failure to request rate adjustment. A provider which fails to request a rate adjustment pursuant to this section may not subsequently request an administrative hearing pursuant to Chapter I regarding the decision to recover overpayments.

(i) Matters not subject to rate adjustment or reconsideration. The following matters are not subject to a rate adjustment pursuant to this section, reconsideration pursuant to Section 17, or an administrative hearing pursuant to Chapter I:

(i) A recovery of overpayments caused by a change in the reimbursement methodology as the result of a change in state or federal law, including a change in these rules; or

(ii) The use or reasonableness of the reimbursement methodology set forth in these rules.

Notes

048-24 Wyo. Code R. §§ 24-16