Sec. 10.09.93.12. Cost Settlement for State-operated Chronic Hospitals — Payments and Appeals

A. The Department or its designee shall notify each provider participating in the Program of the results of the final settlement under Regulation .11 of this chapter.

B. Within 60 days after the provider receives the notification described in §A of this regulation, the Department shall pay the amount due to the provider regardless of whether the provider files an appeal.

C. The provider may request review of the settlement under Regulation .11 of this chapter by filing written notice with the Program’s Appeal Board within 30 days after receipt of the notification of the results of the settlement from the Department or its designee.

D. The Appeal Board shall be composed of the following:

(1) A representative of the hospital industry who is:

(a) Knowledgeable in Medicare and Medicaid reimbursement principles; and

(b) Appointed by the Secretary of the Department;

(2) A person who:

(a) Is employed by the State;

(b) Is knowledgeable in Medicare and Medicaid reimbursement principles;

(c) Did not participate in the verification of costs; and

(d) Is appointed by the Secretary of the Department; and

(3) A third member selected by the first two members of the Appeal Board.

E. When the Appeal Board reviews an appeal from a provider in which an Appeal Board member is employed or in which the member has a financial or personal interest, the Secretary of the Department shall designate an alternate for the member.

F. If the provider elects not to appeal to the Appeal Board:

(1) The provider shall pay the amount due within 60 days after the notification described in §A of this regulation;

(2) If the provider requests a longer payment schedule within 60 days after the provider receives notification of the amount due the Program, the Department may establish, after consultation with the provider, a longer payment schedule; and

(3) The Department shall establish a longer payment schedule if, in the Department’s judgment based on sufficient documentation submitted by the provider, failure to grant a longer payment schedule would:

(a) Result in financial hardship to the provider; or

(b) Have an adverse effect on the quality of participant care furnished by the facility.

G. If the provider elects to appeal to the Appeal Board, the following provisions apply:

(1) Within 30 days after a provider appeals a determination by the Department or its designee that the provider owes money to the Program, the Department or its designee shall:

(a) Recalculate the amount due to the Program based on the verification, exclusive of the amount in controversy which is subject to the appeal; and

(b) Notify the provider of that amount;

(2) In order to enable the Department or its designee to perform this recalculation, the provider shall indicate the specific adjustment and the specific amount being appealed;

(3) Subject to the provisions of §G(4) of this regulation, payment for the amount due the Program, if any, after the recalculation, shall be made within 60 days after the provider receives notification of the recalculation; and

(4) If a provider requests a longer payment schedule within 60 days after the provider receives notification of the recalculation, the Department may establish, after consultation with the provider, a longer payment schedule in accordance with §F(3) of this regulation.

H. Appeal Board Findings.

(1) After the Department receives the findings of the Appeal Board, the Department shall:

(a) Determine the amount that is due either to the Program or to the provider; and

(b) Notify the provider of that amount.

(2) The portion of the amount in controversy that is paid is subject to an award of interest that is:

(a) Calculated from the date the appeal was filed through the date of payment; and

(b) Based on the 6-month Treasury Bill rate in effect on the date the appeal was filed.

(3) Interest paid to a provider under §H(2) of this regulation is not subject to any offset or other reduction against otherwise allowable costs.

(4) If the provider accepted the determination made under §H(1) of this regulation, within 60 days after the provider receives the notification under §H(1) of this regulation, the Program shall pay the amount the Department determined is due the provider, if any.

(5) Subject to §H(6) of this regulation, within 60 days after the provider receives the notification, the provider shall pay the amount due the Program, if any.

(6) If a provider requests a longer payment schedule within 30 days after the provider receives notification of the amount due the Program, the Department may establish, after consultation with the provider, a longer payment schedule in accordance with §F(3) of this regulation.

I. After expiration of the 60-day payment period, or longer payment schedule established by the Department as described in §§F-H of this regulation, and in addition to the sanctions provided in Regulation .14 of this chapter, the Department may recover the unpaid balance by withholding the amount due from the interim payment which would otherwise be payable to the provider.

J. The Department or a provider aggrieved by a reimbursement decision of the Appeal Board may appeal the decision of the Appeal Board as the final decision for judicial review under the Administrative Procedure Act, State Government Article, §10-222, Annotated Code of Maryland.

K. If the provider or the Department appeals the final decision of the Appeal Board, the provider or the Department shall place any money due from the provider or from the Program in an interest-bearing escrow account. The money due shall include the interest, based on the rate in §H(2)(b) of this regulation, calculated from the date of the administrative appeal through the date of opening the escrow account. The money shall remain in escrow until a final decision has been rendered. Upon a final determination of the dispute, the appropriate person administering the escrow account shall distribute the money in that account, including any interest accrued, in conformity with the final determination.

L. The provider may file an appeal of the results of the settlement with the Medicare Appeal Board as a substitute for the Department’s Appeal Board, and the decision rendered by the Medicare Appeal Board will be accepted by the Department as binding.