I CUECs – Provider Audit

30.9.5 – I CUECs – Provider Audit (Rev. 331, Issued: 11-15-19, Effective: 10-01-19, Implementation: 12-17- 19) I – Control Objective Number I – CUEC Description I.1 CMS ensures that applicable CMS systems are appropriately updated. I.2 CMS provides information to the contractor regarding new providers, change of ownership for an existing provider, termination of a provider, or a change of Medicare Administrative Contractor (MAC) to ensure the information is processed in System Tracking for Audit and Reimbursement (STAR) in a timely and accurate manner and reflected in subsequent audit activities. I – Control Objective Number I – CUEC Description 1.3 CMS provides general instructions to ensure that Provider Cost Reports are properly submitted and accepted. Appropriate program policies and instructions are provided to address situations where the provider did not file a cost report. I.4 CMS provides Uniform Desk Review thresholds for determination of limited and full reviews. I.5 CMS provides general instructions to ensure that Provider Cost Reports are issued a Notice of Program Reimbursement timely. I.6 CMS provides general instructions to ensure audit systems (STAR) are updated in compliance with program instructions. I.7 CMS regulations and program policy are provided to ensure that the contractor’s cost report re-opening process is in compliance. I.8 CMS regulations, program policy, and Provider Reimbursement Review Board (PRRB) rules are provided to ensure that the contractor’s appeals process is in compliance. I.9 Control number I.9 reserved. Control not in use as of IOM revision number 278. I.10 CMS provides general instructions for audit work that allows for an internal quality control process to be established. I.11 CMS provides guidelines and instructions to ensure that cost reports are scoped and selected for audit or settled without audit and that audit plans are approved by CMS and in compliance. I.12 CMS provides manual instructions and timelines to ensure that the contractor’s audit process is conducted in compliance, i.e., timeframes for issuance of the engagement letter, documentation requests, pre-exit and exit conferences, and settlement of the audited cost report. I.13 CMS provides instructions for audit programs, desk review programs and CMS audit and reimbursement policies, and other audit related instructions so that they can be communicated to audit staff. I.14 CMS provides instructions to ensure the contractor’s audit staff maintains its necessary knowledge and skills by completing continuing education and training (CET). I – Control Objective Number I – CUEC Description I.15 Supervisory reviews of the audit and settlement process are conducted and the policies and procedures for these reviews are communicated to all supervisors in accordance with CMS program instructions. I.16 All cost reports where fraud and abuse is suspected shall be referred to the Unified Program Integrity Contractor (UPIC) in accordance with CMS and contractor instructions. I.17 The contractor has processes and procedures in place to document that supervisory reviews by provider audit department management were completed on all provider audit Corrective Action Plans (CAPs) from the establishment of the CAPs to the implementation and validation of the CAPs. I.18 HITECH incentive payments for Medicare subsection (d) and critical access hospitals are calculated properly, in accordance with CMS’ regulations, policies, and instructions. Data is properly entered into the FISS screens in order for the HITECH system to generate the incentive payments. I.19 CMS provides instructions and guidelines to ensure that cap determination letters are issued accurately and timely to Hospices and include all related documentation. I.1, I.2, I.3, and I.6 CMS provides a database, System Tracking for Audit and Reimbursement, so that information is accurate and timely. CMS maintains and updates program instructions to ensure that inputs into the STAR system are in compliance. End Section 30.9.5 – I CUECs – Provider Audit: Back to Table of Contents