Sec. 10.09.10.23. Third Party Liability Reviews and Audits of Nursing Facilities

A. Quarterly Reports of Credit Balances. A provider shall report the credit balances of the nursing facility to the Department on a quarterly basis.

B. Third Party Liability Review. The Department shall conduct a third party liability review of the reports of the credit balances provider under §A of this regulation.

C. Third Party Liability Audit of Random Sample. The Department or its designee may conduct a third party liability audit of a random sample of the reports of credit balances reviewed under §B of this regulation.

D. Third Party Liability Audit of Noncompliant Nursing Facility.

(1) Subject to §D(2) of this regulation, the Department or its designee may conduct a third party liability audit of a nursing facility that is found to be noncompliant under §B of this regulation.

(2) In conducting the third party liability audit, the Department or its designee may only review the financial information of the nursing facility for the 2-year period immediately before the first day of the audit period in which the nursing facility was found to be noncompliant.

E. Appeal Rights of Nursing Facility.

(1) A provider may appeal the results of a final report of a third party liability audit by filing written notice with the Department within 30 days after the provider receives the final report from the Department.

(2) An individual at the Department who did not participate in the final report shall:

(a) Review the appeal and contact a provider representative, if clarification is necessary; and

(b) Issue a report that either revises or concurs with the final report of the third party audit.

(3) A provider may appeal the results of the report issued by the Department under §E(2) of this regulation by filing written notice with the Nursing Home Appeal Board within 30 days of receipt of the report.

(4) If the provider does not appeal the results of the third party liability audit by filing written notice with the Department:

(a) The amount due as set out in the final report shall be paid to the Department within 60 days of the receipt by the provider of the results of the third party liability audit; or

(b) On or after the 61st day, after receipt by the provider of the results of the third party liability audit, the Department may withhold the amount as set out in the final report from future payments due the provider by the Department unless an agreed on payment plan has been entered into by the Department and the provider.

(5) If the provider appeals the results of a final report of a third party liability audit as authorized under §E(1) of this regulation, interest shall be charged on the amount appealed and shall continue until date of payment. The interest rate shall be based on the 6-month Treasury Bill rate in effect on the date the appeal was filed.

(6) After a decision adverse to the provider by the Nursing Home Appeal Board and written notice to the provider of that decision by the Department:

(a) The amount determined to be due to the Department as a result of the third party liability audit shall be paid to the Department with accrued interest due; or

(b) On or after the 61st day, the Department may withhold the amount due pursuant to the decision of the Nursing Home Appeal Board from future payments due the provider by the Department unless an agreed on payment plan has been entered into by the Department and the provider.