Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-1-29

Provider-Preventable Conditions

Notice of 120-Day (Emergency) Rule

DAR File No.: 34992
Filed: 06/30/2011 08:23:04 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to implement Section 2702 of the Patient Protection and Affordable Care Act, which issues final regulations on the prohibition of payments for provider-preventable conditions. These final regulations become effective on 07/01/2011.

Summary of the rule or change:

This change implements final regulations on the prohibition of payments for provider-preventable conditions that become effective on 07/01/2011. (DAR NOTE: A corresponding proposed amendment is under DAR No. 34993 in this issue, July 15, 2011, of the Bulletin.)

Emergency rule reason and justification:

Regular rulemaking procedures would place the agency in violation of federal or state law.

Justification: This emergency rule is necessary to implement the final rule on the prohibition of payments for provider-preventable conditions, which was published in the Federal Register on 06/06/2011. These final regulations become effective on 07/01/2011.

State statutory or constitutional authorization for this rule:

• 76 FR 32837
• Section 26-1-5
• Section 26-18-3

This rule or change incorporates by reference the following material:

• Adds Federal Register, published by Government Printing Office, 06/06/2011

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because this rule, through its implementation of federal law, only incorporates existing state practices that prohibit payments for provider-preventable conditions.

local governments:

The Department does not anticipate any impact to local governments because they do not fund or provide Medicaid services.

small businesses:

The Department does not anticipate any impact to small businesses because this rule, through its implementation of federal law, only incorporates existing state practices that prohibit payments for provider-preventable conditions.

persons other than small businesses, businesses, or local governmental entities:

The Department does not anticipate any impact to Medicaid providers because this rule, through its implementation of federal law, only incorporates existing state practices that prohibit payments for provider-preventable conditions. Further, there are no out-of-pocket expenses to Medicaid clients who cannot be billed for these payments.

Compliance costs for affected persons:

The Department does not anticipate any impact to a single Medicaid provider because this rule, through its implementation of federal law, only incorporates existing state practices that prohibit payments for provider-preventable conditions. Further, there are no out-of-pocket expenses to a single Medicaid client who cannot be billed for these payments.

Comments by the department head on the fiscal impact the rule may have on businesses:

Current practice prohibits billing for services where actions by the provider created the need for the care. Any impact on business is justified. Taxpayers should not pay for the preventable mistakes of providers.

W. David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

This rule is effective on:

07/01/2011

Authorized by:

David Patton, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-1. Utah Medicaid Program.

R414-1-29. Provider-Preventable Conditions.

The following applies to inpatient hospital services provided to Medicaid recipients and dual eligible beneficiaries:

(1) In accordance with 76 FR 32837, which is incorporated by reference, Medicaid will not reimburse providers or contractors for provider-preventable conditions as defined in this CMS rule. Providers and contractors are prohibited from submitting claims for payment of these conditions except as permitted in 76 FR 32837 when the provider-preventable condition existed prior to the initiation of treatment by the provider.

(2) Medicaid providers who treat Medicaid eligible patients must report all provider- preventable conditions whether or not reimbursement for the services is sought. Medicaid providers must complete the Provider-Preventable Conditions Report as found at http://health.utah.gov/medicaid/index.html. Completed reports must be mailed to one of the following addresses within 30 calendar days of the event, as appropriate:

(a) Via U.S. Post Office: Utah Department of Health; DHCF, BCRP; Attn: Provider-Preventable Conditions Reporting; PO Box 143102; Salt Lake City, UT 84114-3102; or

(b) Via UPS or FedEx: Utah Department of Health; DHCF, BCRP; Attn: Provider-Preventable Conditions Reporting; 288 North 1460 West; Salt Lake City, UT 84116-3231.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: July 1, 2011

Notice of Continuation: April 16, 2007

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-34-2