471 Neb. Admin. Code, ch. 46, § 022

Current through June 17, 2024

Section 471-46-022 - REQUEST FOR RATE ADJUSTMENTS

Requests for rate adjustments are subject to the rules contained in this section.

022.01REQUESTS. Hospitals may submit a request to the Department for an adjustment to their rates for the following:

(A) An error in the calculation of the rate. Hospitals may submit a request for adjustment to their rate if the rate-setting methodology or principles of reimbursement established under the State Plan were incorrectly applied, or if incorrect data or erroneous calculations were used in the establishment of the hospital's rate;

(B) Extraordinary circumstances. Hospitals may submit a request for adjustment to their rate for extraordinary circumstances that are not faced by other Nebraska hospitals in the provision of hospital services. Extraordinary circumstances are limited to circumstances occurring since the base year that are not addressed by the reimbursement methodology. Extraordinary circumstances are limited to:

(i) Changes in routine and ancillary costs, which are limited to:

(1) Intern and resident related medical education costs; and

(2) Establishment of a subspecialty care unit.

(ii) Extraordinary capital-related costs. Adjustment for capital-related costs will be limited to no more than a five percent increase.

(C) Catastrophic circumstances. Hospitals may submit a request for adjustment to their rate if they incur allowable costs as a consequence of a natural or other catastrophe. The following circumstances must be met to be considered a catastrophic circumstance:

(i) One-time occurrence;

(ii) Less than twelve-month duration;

(iii) Could not have been reasonably predicted;

(iv) Not of an insurable nature;

(v) Not covered by federal or state disaster relief; and

(vi) Not a result of malpractice or negligence.

022.02CALCULABLE. In all circumstances, requests for adjustments to rates must be calculable and auditable. Requests must specify the nature of the adjustment sought and the amount of the adjustment sought. The burden of proof is that of the requesting hospital. If an adjustment is granted, the peer group rates will not be changed.

022.03RATE ADJUSTMENT REQUIREMENTS. In making a request for adjustment for circumstances other than a correction of an error, the requesting hospital shall demonstrate the following, changes in costs are the result of factors generally not shared by other hospitals in Nebraska, such as improvements imposed by licensing or accrediting standards, or extraordinary circumstances beyond the hospital's control; every reasonable action has been taken by the hospital to mitigate or contain resulting cost increases. The Department may request that the hospital provide additional quantitative and qualitative data to assist in evaluation of the request. The Department may require an on-site operational review of the hospital be conducted by the Department or its designee; the rate the hospital receives is insufficient to provide care and service that conforms to applicable state and federal laws, regulations, and quality and safety standards.

022.04RATE ADJUSTMENT REQUEST SUBMISSION. Requests for rate adjustments must be submitted in writing to the Division. Requests must be received within 45 days after one of the above circumstances occurs or the notification of the facility of its prospective rates. Upon receipt of the request, the Department shall determine the need for a conference with the hospital and will contact the facility to arrange a conference if needed. The conference, if needed, must be held within 60 days of the Department's receipt of the request. Regardless of the Department's decision, the provider will be afforded the opportunity for a conference if requested for a full explanation of the factors involved and the Department's decision. Following review of the matter, the administrator shall notify the facility of the action to be taken by the Department within 30 days of receipt of the request for review or the date of the conference, except in circumstances where additional information is requested or additional investigation or analysis is determined to be necessary by the Department.

022.05APPLICABILITY. If rate relief is granted as a result of a rate adjustment request, the relief applies only to the rate year for which the request is submitted, except for corrections of errors in rate determination. If the provider believes that continued rate relief is justified, a request in any subsequent year may be submitted.

022.06NO EXCEEDING ACTUAL MEDICAID COST. Under no circumstances shall changes in rates resulting from the request process result in payments to a hospital that exceed its actual Medicaid cost, calculated in conformity with this Medicaid cost calculation methodology.

471 Neb. Admin. Code, ch. 46, § 022

Adopted effective 6/6/2022