AGING AND DISABILITY SERVICES ADMINISTRATION

2006 NH "Dear Administrator" Letters

November 30, 2006

ADSA: NH #2006-029
CASE MIX ACCURACY REVIEW (CMAR)
INFORMAL ADMINISTRATIVE HEARING

Dear Nursing Facility/Home Administrator

On October 1, 1998, the Medicaid Case-Mix payment system was implemented in Washington State. In order to verify the accuracy of facility case-mix data used to establish and update Medicaid payment rates, the Department of Social and Health Services through Residential Care Services (RCS) was required to perform periodic on-site accuracy reviews of the MDS assessment of nursing facility residents.

Quality Assurance Nurses (QANs) from RCS conduct the accuracy reviews approximately every 12-15 months. The results of the reviews, preliminary findings, are shared by the QAN in an exit conference with the nursing home administrator and any other staff the facility identifies. Every attempt to resolve differences and provide additional information or clarification, including documentation, should be made prior to the exit conference.

Within 5 days of the exit conference, the RCS Field Manager for the nursing home will send the Case-Mix Accuracy Review (CMAR) decision letter to the nursing home. The provider may appeal any of the CMAR findings through an informal administrative hearing process.

• The appeal request should be sent in writing within ten (10) calendar days of the receipt of the CMAR decision letter. The address for mailing this appeal request is noted in the CMAR decision letter.
• The request must be signed by the authorized facility representative and identify the specific item(s) that are in dispute and why the facility feels the CMAR results are in error. The facility may include additional documentation or other information related to the request.

The Case-Mix Accuracy Review Program Manager or a designee will contact the provider by telephone to schedule the informal hearing within ten (10) days of receipt of the request for the review. The hearing may be conducted in person, by telephone, by review of documentation, or any combination of these methods. Whenever possible, the hearing will be scheduled within two weeks of the date the CMAR Program Manager contacts the provider.

The purpose of the informal hearing is to offer the provider one opportunity to present documentation and information that might warrant a change to the resident specific accuracy findings noted in the case mix accuracy review. The hearing will focus on clinical issues of resident need and assessment. The hearing will not include issues beyond the scope of appeal, such as remedies or negative actions imposed by the department to correct practices or inaccuracies; alleged inconsistencies in the accuracy review process; challenges to the authority or adequacy of the CMAR; or, payment rate issues.

The CMAR Program Manager will review the issues, any additional information or supporting documentation that has been previously sent or requested and the working papers from the Quality Assurance Nurse’s review. The hearing will occur as previously determined by the provider and the review administrator.

Within ten (10) working days after the informal hearing or within ten (10) working days of receiving additional information (whichever is later), the review administrator will notify the provider of the decision. The determination will be to either uphold the facility coding or support the Quality Assurance Nurse’s findings of an MDS item inaccuracy.

If the decision is made to uphold the nursing home’s coding of the MDS item(s), the review administrator will:

• Revise the QAN review forms to reflect changes;
• Revise the preliminary summary report; and
• Enter the corrected data into the ADSA database.

If the determination supports the QAN’s findings, all reports and data will be finalized as they appeared at the completion of the accuracy review.

The results of the informal hearing will be sent to the provider in writing via regular mail. The results represent the final agency decision and, if the provider is dissatisfied with the results, the provider may petition for judicial review under the state’s Administrative Procedure Act (RCW 34.05).

A copy of the informal hearing results will be sent to the appropriate RCS Field Manager.
A copy of the hearing results along with all materials used in the informal administrative hearing will be retained in the facility case-mix file located at the ADSA headquarters office in Lacey.

If you have any questions about this issue, please contact Marjorie Ray, CMAR Program Manager, at (360) 725-2487.

Sincerely,

Joyce Pashley Stockwell, Director
Residential Care Services

cc: Regional Administrators
Ken Callaghan