N.J. Admin. Code § 10:52-11.15

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:52-11.15 - Adjustment methodology

(a) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise:

"Alternative documentation adjustment" means an adjustment to a hospital's charity care write-off amount as a result of the periodic audits of a sample of claims submitted during a calendar year. This audit determines whether the total value of sampled claims that are documented by the alternative procedures described in 10:52-11.6(a)3, 11.7(a)3, 11.9(a)3 or 11.10(d)3, exceeds permitted limits.

"Charity care write-off amount" means the rendered charity care services, priced at the rate used by the Medicaid program before adjustment, if any, for direct graduate medical education and indirect medical education factors.

"Compliance adjustment" means an adjustment to a hospital's charity care write-off amount as a result of the periodic audits of a sample of claims submitted during a calendar year. This audit determines whether there is appropriate documentation showing that all charity care eligibility requirements at 10:52-11.5 through 11.11 and 11.16 have been met.

"Listing adjustment" means an adjustment to a hospital's charity care write-off amount as a result of the audit of a sample of these claims submitted during a calendar year. The purpose of this audit is to ensure that the claims contain only those charges that are eligible for reimbursement.

(b) The charity care write-off amount for each account should agree with the reimbursement rate that would have been paid to the hospital by the Medicaid/NJ FamilyCare program. To the extent that a hospital's total charity care write-off amount is overstated, the amount will be reduced by the amount of the overstatement.

(c) In addition to adjustments required to ensure that the charity care write-off amount is equal to the Medicaid/NJ FamilyCare reimbursement rates, the write-off amount may also be revised on the basis of listing, alternative documentation and/or compliance adjustments, in that order.

(d) Examples of listing adjustments include changes made if:

1. Medicare or other third-party payer payments were not reflected in the claim;

2. Ineligible expenses, such as standard convenience or personal comfort items as listed in Uniform Billing requirements, are included; or

3. The percentage of the claim to be written off to charity care, based on the hospital's determination of the applicant's eligibility, was erroneous.

(e) In accordance with the provisions of N.J.A.C. 10:52-11.11, use of alternative documentation in any one of the steps to determine an applicant's eligibility for charity care shall cause that applicant's file to be designated as an alternative documentation file. A ratio shall be developed using sample dollars with alternative documentation as a percentage of total sample dollars. If this ratio is less than or equal to.10, there shall be no adjustment. If this ratio is greater than.10, the ratio shall be reduced by.10 and then multiplied by the hospital's charity care write-off amount at the Medicaid/NJ FamilyCare rate for the calendar year being audited. This amount shall be subtracted from the hospital's charity care write-off amount for the calendar year being audited at the Medicaid rate after listing adjustment.

(f) In accordance with the provisions of N.J.A.C. 10:52-11.5 through 11.11, noncompliance with any one of the steps to determine an applicant's eligibility for charity care shall cause that applicant's file to be designated as a failed compliance file. A ratio shall be developed using sample dollars from failed compliance files as a percentage of total sample dollars. If this ratio is less than.10, there shall be no adjustment. If this ratio is equal to or greater than.10, the ratio shall be multiplied by the hospital's charity care write-off amount for the calendar year being audited at the Medicaid/NJ FamilyCare rate. This amount shall be subtracted from the hospital's charity care write-off amount at the Medicaid rate after alternative documentation adjustment.

(g) The hospital's charity care write-off amount total adjusted for (d), (e) and (f) above will constitute the hospital's audited charity care write-off amount for claims submitted during the calendar year being audited, except for further adjustments that may occur in accordance with 10:52-13.4.

(h) The Department of Health's auditor will provide the hospital with a copy of its audit findings and recommended adjustments. Eligible hospitals shall sign the auditor's audit findings, indicating their agreement or disagreement with the audited charity care write-off amount. If the hospital disagrees with the audit findings, the hospital shall submit a request for a departmental review within 15 days of receiving the auditor's report and shall, within the request, detail the reasons for disagreement with the auditor's findings. The Department will review the auditor's findings, as well as the hospital's objections, and will advise the hospital within 30 days of receipt of the request for review of the total dollar value of the hospital's charity care write-off for the period audited, priced at the Medicaid/NJ FamilyCare rate.

(i) A hospital which disagrees with the audit findings may request an administrative hearing, which shall be conducted in accordance with the Administrative Procedure Act, 52:14B-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.

N.J. Admin. Code § 10:52-11.15

Amended by 50 N.J.R. 1261(a), effective 5/21/2018