49.45(3)(e)9.
9. Hospital research costs that the department finds to be indirectly related to patient care are not allowable costs in establishing a hospital's reimbursement or payment rate under
subd. 1.
49.45(3)(e)10.
10. Hospital procedures on an inpatient basis that could be performed on an outpatient basis shall be reimbursed or paid at the outpatient rate. The department shall determine which procedures this subdivision covers.
49.45(3)(f)1.1. Providers of services under this section shall maintain records as required by the department for verification of provider claims for reimbursement. The department may audit such records to verify actual provision of services and the appropriateness and accuracy of claims.
49.45(3)(f)2.
2. The department may deny any provider claim for reimbursement which cannot be verified under
subd. 1. or may recover the value of any payment made to a provider which cannot be so verified. The measure of recovery will be the full value of any claim if it is determined upon audit that actual provision of the service cannot be verified from the provider's records or that the service provided was not included in
s. 49.46 (2). In cases of mathematical inaccuracies in computations or statements of claims, the measure of recovery will be limited to the amount of the error.
49.45(3)(f)2m.
2m. The department shall adjust reimbursement claims for hospital services that are provided during a period when the recipient awaits placement in an alternate custodial living arrangement under
par. (e) 7. and that fail to meet criteria the department may establish concerning medical necessity or appropriateness for hospital care. In addition, the department shall deny any provider claim for services that fail to meet criteria the department may establish concerning medical necessity or appropriateness.
49.45(3)(f)3.
3. Contractors under
sub. (2) (b) shall maintain records as required by the department for audit purposes. Contractors shall provide the department access to the records upon request of the department, and the department may audit the records.
49.45(3)(g)
(g) The secretary may appoint personnel to audit or investigate and report to the department on any matter involving violations or complaints alleging violations of laws, regulations, or rules applicable to Title XIX of the federal social security act or the medical assistance program and to perform such investigations or audits as are required to verify the actual provision of services or items available under the medical assistance program and the appropriateness and accuracy of claims for reimbursement submitted by providers participating in the program. Department employes appointed by the secretary under this paragraph shall be issued and shall possess at all times during which they are performing their investigatory or audit functions under this section identification signed by the secretary which specifically designates the bearer as possessing the authorization to conduct medical assistance investigations or audits. Pursuant to the request of a designated person and upon presentation of that person's authorization, providers and recipients shall accord such person access to any records, books, recipient medical records, documents or other information needed. Authorized employes shall have authority to hold hearings, administer oaths, take testimony and perform all other duties necessary to bring such matter before the department for final adjudication and determination.
49.45(3)(h)1.1. For purposes of any audit, investigation, examination, analysis, review or other function authorized by law with respect to the medical assistance program, the secretary shall have the power to sign and issue subpoenas to any person requiring the production of any pertinent books, records, medical records or other information. Subpoenas so issued shall be served by anyone authorized by the secretary by delivering a copy thereof to the person named therein, or by registered mail or certified mail addressed to such person at his or her last-known residence or principal place of business. A verified return by the person so serving the subpoena setting forth the manner of service, or, in the event service is by registered or certified mail, the return post-office receipt signed by the person so served shall constitute proof of service.
49.45(3)(h)2.
2. In the event of contumacy or refusal to obey a subpoena issued under this paragraph and duly served upon any person, any judge in a court of record in the county where the person was served may enforce the subpoena in accordance with
s. 885.12.
49.45(3)(h)3.
3. The failure or refusal of a person to purge himself or herself of contempt found under
s. 885.12 and perform the act as required by law shall constitute grounds for decertification or suspension of that person from participation in the medical assistance program and no payment may be made for services rendered by that person subsequent to decertification or during the period of suspension.
49.45(3)(i)
(i) The department may not reimburse a provider for certain elective surgical procedures without a 2nd opinion from another provider. Second opinions are required for selected elective surgical procedures for which 2nd opinions disagree with the original opinions at demonstrably high rates. The department shall notify the providers of the surgical procedures for which a 2nd opinion is required.
49.45(3)(j)
(j) Reimbursement for administrative contract costs under this section is limited to the funds available under
s. 20.435 (1) (bm).
49.45(3)(k)
(k) If a physician performs a surgical procedure that is within the scope of practice of a podiatrist, as defined in
s. 448.01 (7), the allowable charge for the procedure may not exceed the charge the department determines is reasonable.
49.45(3)(L)2.
2. The department may not pay a provider for a designated health service that is authorized under this section or
s. 49.46 or
49.47, that is provided as the result of a referral made to the provider by a physician and that, under
42 USC 1396b (s), if made on behalf of a beneficiary of medicare under the requirements of
42 USC 1395nn, as amended to August 10, 1993, would result in the denial of payment for the service under
42 USC 1395nn.
49.45(3)(L)3.
3. A provider shall submit to the department information concerning the ownership arrangements of the provider or the entity of which the provider is a part that corresponds to the information required of providers under
42 USC 1395nn (f), as amended to August 10, 1993.
49.45(3)(L)4.
4. Any person who fails to comply with
subd. 3. may be required to forfeit not more than $10,000. Each day of continued failure to comply constitutes a separate offense.
49.45(4)
(4) Information restricted. The use or disclosure of any information concerning applicants and recipients of medical assistance not connected with the administration of this section is prohibited.
49.45(5)
(5) Appeal. Any person whose application for medical assistance is denied or is not acted upon promptly or who believes that the payments made in the person's behalf have not been properly determined may file an appeal with the department pursuant to
s. 49.21 (1).
49.45(5m)
(5m) Supplemental funding for rural hospitals. 49.45(5m)(a)(a) Notwithstanding
sub. (3) (e), from the appropriations under
s. 20.435 (1) (b) and
(o) the department shall distribute not more than $2,256,000 in each fiscal year, to provide supplemental funds to rural hospitals that, as determined by the department, have high utilization of inpatient services by patients whose care is provided from governmental sources, except that the department may not distribute funds to a rural hospital to the extent that the distribution would exceed any limitation under
42 USC 1396b (i) (3).
49.45(5m)(b)
(b) The supplemental funding under
par. (a) shall be based on the utilization, by recipients of medical assistance, of the total inpatient days of a rural hospital in relation to that utilization in other rural hospitals.
49.45(6b)
(6b) Centers for the developmentally disabled. From the appropriation under
s. 20.435 (2) (gk), the department may reimburse the cost of services provided by the centers for the developmentally disabled. Reimbursement to the centers for the developmentally disabled shall be reduced following each placement made under
s. 46.275 which involves a relocation from a center for the developmentally disabled, as follows:
49.45(6b)(a)
(a) Beginning in fiscal year 1995-96, for relocations from the central Wisconsin center for the developmentally disabled, by $205 per day.
49.45(6b)(b)
(b) Beginning in fiscal year 1995-96, for relocations from the northern Wisconsin center for the developmentally disabled, by $199 per day.
49.45(6b)(c)
(c) Beginning in fiscal year 1995-96, for relocations from the southern Wisconsin center for the developmentally disabled, by $149 per day.
49.45(6c)
(6c) Preadmission screening and resident review. 49.45(6c)(a)1.
1. "Active treatment for developmental disability" means a continuous program for an individual who has a developmental disability that includes aggressive, consistent implementation of specialized and generic training, treatment, health services and related services, that is directed toward the individual's acquiring behaviors necessary for him or her to function with as much self-determination and independence as possible and that is directed toward preventing or decelerating regression or loss of the individual's current optimal functional status. "Active treatment for developmental disability" does not include services to maintain generally independent individuals with developmental disability who are able to function with little supervision or in the absence of active treatment for developmental disability.
49.45(6c)(a)2.
2. "Active treatment for mental illness" means the implementation of an individualized plan of care for an individual with mental illness that is developed under and supervised by a physician licensed under
ch. 448 and other qualified mental health care providers and that prescribes specific therapies and activities for the treatment of the individual while the individual experiences an acute episode of severe mental illness which necessitates supervision by trained mental health care providers.
49.45(6c)(a)4.
4. "Developmental disability" means any of the following:
49.45(6c)(a)4.a.
a. Significantly subaverage general intellectual functioning that is concurrent with an individual's deficits in adaptive behavior and that manifested during the individual's developmental period.
49.45(6c)(a)6.
6. "Facility care" means services provided in a facility that are in conformity with
42 USC 1396r and that are payable under
sub. (6m).
49.45(6c)(b)
(b)
Preadmission screening. Except as provided in
par. (e), beginning on August 9, 1989, every individual who applies for admission to a facility or to an institution for mental diseases shall be screened to determine if the individual has developmental disability or mental illness. Beginning on August 9, 1989, the department or an entity to which the department has delegated authority shall screen every individual who has been identified as having a developmental disability or mental illness to determine if the individual needs facility care. If the individual is determined to need facility care, the department or an entity to which the department has delegated authority shall also assess the individual to determine if he or she requires active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(c)
(c)
Resident review. Except as provided in
par. (e), by April 1, 1990, and at least annually thereafter, the department or an entity to which the department has delegated authority shall review every resident of a facility or institution for mental diseases who has a developmental disability or mental illness to determine if any of the following applies:
49.45(6c)(c)2.
2. The resident requires active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(d)1.1. No payment may be made under
sub. (6m) to a facility or to an institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under
s. 49.46 or
49.47, who has developmental disability or mental illness and for whom under
par. (b) or
(c) it is determined that he or she does not need facility care, unless it is determined that the individual requires active treatment for developmental disability or active treatment for mental illness and has continuously resided in a facility or institution for mental diseases for at least 30 months prior to the date of the determination. If that individual requires active treatment and has so continuously resided, he or she shall be offered the choice of receiving active treatment for developmental disability or active treatment for mental illness in the facility or institution for mental diseases or in an alternative setting. A facility resident who has developmental disability or mental illness, for whom under
par. (c) it is determined that he or she does not need facility care and who has not continuously resided in a facility for at least 30 months prior to the date of the determination, may not continue to reside in the facility after December 31, 1993, and shall, if the department so determines, be relocated from the facility after March 31, 1990, and before December 31, 1993. The county department shall be responsible for securing alternative residence on behalf of an individual who is required to be relocated from a facility under this subdivision, and the facility shall cooperate with the county department in the relocation.
49.45(6c)(d)2.
2. Payment may be made under
sub. (6m) to a facility or institution for mental diseases for the care of an individual who is otherwise eligible for medical assistance under
s. 49.46 or
49.47 and who has developmental disability or mental illness and is determined under
par. (b) or
(c) to need facility care, regardless of whether it is determined under
par. (b) or
(c) that the individual does or does not require active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(e)1.1. Payment under
sub. (6m) may be made to a facility and no screening under
par. (b) or review under
par. (c) is required for an individual who is medically diagnosed as having developmental disability or mental illness, and who is not a danger to himself or herself or to others, if, immediately after release from a hospital, the individual enters the facility, as part of a medically prescribed period of recovery, for a period not to exceed 30 days and the admission is approved by the department or an entity to which the department has delegated authority.
49.45(6c)(e)2.
2. Payment under
sub. (6m) may be made to a facility or institution for mental diseases for an individual who is 65 years of age or older, is medically diagnosed as having developmental disability or mental illness, is not a danger to himself or herself or to others and is competent to make an independent decision, if, following screening under
par. (b) or review under
par. (c), all of the following apply:
49.45(6c)(e)2.a.
a. It is determined that the individual needs facility care and requires active treatment for developmental disability or active treatment for mental illness.
49.45(6c)(e)2.b.
b. The individual chooses not to participate in active treatment.
49.45(6c)(f)
(f)
Hearing. An individual for whom admission to a facility or institution for mental diseases is denied under
par. (b) or for whom a determination under
par. (c) results in prohibition of payment to a facility or institution for mental diseases under
par. (d) and relocation from the facility to a facility or institution for mental diseases may request a hearing from the department.
49.45(6c)(g)
(g)
Rule making. The department shall promulgate all of the following rules:
49.45(6c)(g)1.
1. Establishing criteria and procedures for a determination by the department under
par. (d) that a resident be relocated from a facility after March 31, 1990, and before December 31, 1993.
49.45(6h)
(6h) Liability for disallowances. If the department or the federal health care financing administration finds a skilled nursing facility or intermediate care facility in this state that provides care to medical assistance recipients for which the facility receives reimbursement under
sub. (6m) to be an institution for mental diseases, the facility shall be liable for any retroactive federal medicaid disallowances for services provided after the date of the finding.
49.45(6j)
(6j) Limitation on certain facility coverage. The department shall determine, under a method devised by the department, the average population during the period from January 1, 1987, to June 30, 1988, of persons in each skilled nursing facility or an intermediate care facility who are mentally ill and are aged 21 to 64, except persons under 22 years of age who were receiving medical assistance services in the facility prior to reaching age 21 and continuously thereafter. Beginning July 1, 1988, the payment under
sub. (6m) for services provided by a facility to persons who are mentally ill and are within the age limitations specified in this subsection may not exceed the payment for the average population of these persons in that facility, as determined by the department.
49.45(6m)(a)2.
2. "Cost center" means a group of similar facility expenses.
49.45(6m)(a)3.
3. "Facility" means a nursing home as defined under
s. 50.01 (3) or a community-based residential facility that is licensed under
s. 50.03 and that is certified by the department as a provider of medical assistance.
49.45(6m)(a)4.
4. "Net property tax" means property tax from which the Wisconsin state property tax credit has been deducted.
49.45(6m)(ag)
(ag) Payment for care provided in a facility under this subsection made under
s. 20.435 (1) (b),
(o) or
(p) shall, except as provided in
pars. (bg),
(bm) and
(br), be determined according to a prospective payment system updated annually by the department. The payment system shall implement standards which are reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated facilities in order to provide care in conformity with this section, with federal regulations authorized under
42 USC 1396a (a) (13) (A),
1396a (a) (30),
1396b (i) (3),
1396L and
1396r (e) and with quality and safety standards established under
subch. II of ch. 50 and
ch. 150. In administering this payment system, the department shall allow costs it determines are necessary and proper for providing patient care. The payment system shall reflect all of the following:
49.45(6m)(ag)1.
1. A prudent buyer approach to payment for services, under which a reasonable price recognizing selected factors that influence costs is paid for service that is of acceptable quality.
49.45(6m)(ag)2.
2. Standards established by the department for costs of economically and efficiently operated facilities that shall be based upon allowable costs incurred by facilities in the state as available from information submitted under
par. (c) 3. and compiled by the department.
49.45(6m)(ag)3m.
3m. For state fiscal year 1995-96, rates that shall be set by the department based on information from cost reports for the 1994 fiscal year of the facility and for state fiscal year 1996-97, rates that shall be set by the department based on information from cost reports for the 1995 fiscal year of the facility.
49.45(6m)(ag)6.
6. Standards for capital payment that will be based upon replacement value of a facility as determined by a commercial estimator with which the department contracts and criteria and limitations as determined by the department.
49.45(6m)(ag)7.
7. Assurance of an acceptable quality of care for all medical assistance recipients provided nursing home care.
49.45(6m)(ag)8.
8. Calculation of total payments and supplementary payments to facilities that permits an increase in funds allocated under
s. 20.435 (1) (b) and
(o) for nursing home care provided medical assistance recipients over that paid for services provided in state fiscal year 1994-95 of no more than 4.25% during state fiscal year 1995-96 and over that paid for services provided in state fiscal year 1995-96 of no more than 3.5% during state fiscal year 1996-97, excluding increases in total payments attributable to increases in recipient utilization of facility care, payments for the provision of active treatment to facility residents with developmental disability or chronic mental illness and payments for preadmission screening of facility applicants and annual reviews of facility residents required under
42 USC 1396r (e).
49.45(6m)(am)
(am) In determining payments for a facility under the payment system in
par. (ag), the department shall consider all of the following cost centers:
49.45(6m)(am)1.
1. Allowable direct care costs, including, if provided, any of the following:
49.45(6m)(am)1.d.
d. Services of facility medical personnel that are not separately billable under medical assistance requirements.
49.45(6m)(am)1.e.
e. Nonbillable services of a registered nurse, licensed practical nurse, nursing assistant, ward clerk, activity person, recreation person, social worker, volunteer coordinator, teacher for residents aged 22 and older, vocational counselor for residents aged 22 and older, religious person, therapy aide, therapy assistant and counselor on resident living.
49.45(6m)(am)2.
2. Allowable support service costs, including the following allowable facility expenses:
49.45(6m)(am)2.a.
a. Dietary service for the provision of meals to facility residents.
49.45(6m)(am)2.b.
b. Environmental service for the provision of maintenance, housekeeping, laundry and security service.
49.45(6m)(am)3.
3. Allowable fuel and utility costs, including the facility expenses that the department determines are allowable for the provision of:
