Final Settlement Process - Medicare Cost-Based HMO/CMPs

20.2.1 - Final Settlement Process - Medicare Cost-Based HMO/CMPs (Rev. 4, 10-01-01) Final settlement with a cost-based HMO/CMP is based on information in the independently certified cost report and payments previously made under interim settlement procedures, subject to the Medicare program's standard audit and retroactive adjustment procedures. In addition, CMS retains the right to conduct an independent audit of the information contained in the final certified cost report. A final settlement may be made with the HMO/CMP even though a provider of services has not had a final settlement with CMS for services furnished to Medicare beneficiaries not enrolled in the HMO/CMP. This exception does not apply if the provider is owned or operated by the HMO/CMP or related to the HMO/CMP by common ownership or control. CMS will only permit this exception if CMS is satisfied that prompt settlement would be in the best interest of the Medicare program, as shown by such factors as: • The provider's costs represent an insignificant amount of the HMO/CMP's total payment; or • CMS is satisfied that the provider's costs for serving the HMO/CMP's enrollees will not be modified significantly by the final settlement with the provider under 42 CFR Parts 412 and 413. Final settlement for cost-based HMO/CMPs will equal the total reimbursable costs incurred by or on behalf of the HMO/CMP throughout the contract period for furnishing covered care to the HMO/CMP's Medicare enrollees (less applicable deductible and coinsurance). Once the final determination of reasonable costs is made, CMS will promptly notify the HMO/CMP by sending a Notice of Program Reimbursement (NPR). This notice will: • Explain CMS’s determination regarding total reimbursement, including an explanation of the computation of overpayments or underpayments; • Relate this determination to the HMO/CMP claimed total reimbursement; • Explain differences between the HMO/CMP's and CMS’s determination; and • Inform the HMO/CMP of its right to have the determination reviewed at a hearing.