Maintenance of and Access to MA-Related Record

110.4.3 - Maintenance of and Access to MA-Related Record Requirements (Rev. 79, Issued 02-17-06, Effective Date 02-17-06) DHHS, the Comptroller General, or their designees may audit, evaluate, or inspect any books, contracts, medical records, patient care documentation, and other records of the MA organization or relating to the MA organization's MA contract. DHHS, the Comptroller General, or their designees may audit, evaluate, or inspect any books, contracts, medical records, patient care documentation, and other records of the related entity, contractor, subcontractor, or its transferee that pertain to any aspect of services performed, reconciliation of benefit liabilities, and determination of amounts payable under the contract, or as the Secretary may deem necessary to enforce the MA contract. The MA organization agrees to make available its premises, physical facilities and equipment, records relating to its Medicare enrollees, and any additional relevant information that CMS may require. Pursuant to these requirements, the MA organization further agrees that it must maintain the following types of books, records, documents, and other evidence of accounting procedures and practices for 10 years from the end date of an MA contract or the completion date of an audit, whichever is later. • Records sufficient to accommodate periodic auditing of the financial records (including data related to Medicare utilization, costs, encounter data, and computation of the bid proposal); • Records sufficient to enable CMS to inspect or otherwise evaluate the quality, appropriateness and timeliness of services performed under the contract and the facilities of the organization; • Records sufficient to enable CMS to audit and inspect any books and records of the MA organization that pertain to the ability of the organization to bear the risk of potential financial losses, to services performed, or determinations of amounts payable under the contract; • Records sufficient to properly reflect all direct and indirect costs claimed to have been incurred and used in the preparation of the bid proposal; • Records sufficient to establish component rates of the bid proposal for determining additional and supplementary benefits; • Records sufficient to determine the rates utilized in setting premiums for State insurance agency purposes, and for other government and private purchasers; • Records relating to ownership and operation of the MA organization's financial, medical, and other record keeping systems; • Financial statements for the current contract period and 10 prior periods; • Federal income tax or informational returns for the current contract period and 10 prior periods; • Asset acquisition, lease, sale, or other ownership issues; • Agreements, contracts, and subcontracts; • Franchise, marketing, and management agreements; • Schedules of charges for the MA organization's fee-for-service patients; • Documentation of matters pertaining to costs of operations; • Documentation of amounts of income received by source and payment; • Cash Flow statements; and • Any financial reports filed with other Federal programs or State authorities; This requirement includes allowing DHHS, the Comptroller General, or their designee to have access to facilities and records to evaluate through inspection or other means: • The quality, appropriateness, and timeliness of services furnished to Medicare enrollees under the contract; • The facilities of the MA organization; and • The enrollment and disenrollment records for the current contract period and 10 prior contract periods. DHHS, the Comptroller General, or their designee's right to inspect, evaluate, and audit extends through 10 years from the final date of the contract period or completion of audit, whichever is later unless: • CMS determines there is a special need to retain a particular record or group of records for a longer period. CMS notifies the MA organization at least 30 days before the normal disposition date; • There has been a termination, dispute, or fraud or similar fault by the MA organization, in which case the retention may be extended to six years from the date of any resulting final resolution of the termination, dispute, or fraud or similar fault; or • CMS determines that there is a reasonable possibility of fraud, in which case it may inspect, evaluate, and audit the MA organization at any time. NOTE: See 42 CFR 423.504(b)(4)(vi)(H) for additional requirements relating to fraud, waste, and abuse that MA organizations offering a prescription drug benefit under Part D must follow.