I Controls – Provider Audit

50.9 – I Controls – Provider Audit (Rev. 331, Issued: 11-15-19, Effective: 10-01-19, Implementation: 12-17- 19) I – Control Number Control Objective – Provider Audit I.1 Interim, tentative and PIP payments to Medicare providers are established, monitored and adjusted, if necessary, in a timely and accurate manner in accordance with CMS general instructions and provider payment files are updated in a timely and accurate manner. Adjustments to interim payments shall be made to ensure that payments approximate final program liability within established ranges. Payment records are adequately protected. All applicable CMS systems are properly updated. I.2 Information received by the contractor from CMS or obtained from other sources regarding new providers, change of ownership for an existing provider, termination of a provider, or a change of Medicare Administrative Contractor (MAC) are identified, recorded, and processed in System Tracking for Audit and Reimbursement (STAR) in a timely and accurate manner and reflected in subsequent audit activities. I.3 Provider Cost Reports are properly submitted and accepted in accordance with CMS’ regulations, policies, and instructions. Appropriate program policies and instructions are followed in situations where the provider did not file a cost report. Cost report submission information is timely and properly forwarded to the proper CMS Systems. I.4 Desk review procedures and work performed are documented and are sufficient to obtain an accurate review of the submitted cost report and are in accordance with the Uniform Desk Review (UDR) Program. Documentation is established and maintained to identify situations requiring a limited desk review or a full desk review. I.5 Notices of Program Reimbursement (NPR) are issued accurately and timely to providers and include all related documentation (e.g. an audit adjustment report, copy of the final settled cost report). I.6 Inputs to mandated systems regarding provider audit, settlement, reopening, appeals, and reimbursement performance (STAR) are complete, accurate and in compliance with program instructions. Documentation supporting reports and inputs shall be maintained. I.7 The contractor’s cost report reopening process is conducted in accordance with CMS regulations and program policy. I.8 Provider appeals (including both the Provider Reimbursement Review Board (PRRB) and Contractor Appeals) are handled appropriately. Jurisdictional questions are addressed and PRRB timeframes for submission are observed. I – Control Number Control Objective – Provider Audit I.9 Control number I.9 reserved. Control not in use as of IOM revision number 278. I.10 An internal quality control process has been established and is functioning in accordance with CMS instructions to ensure that audit work performed on providers’ cost reports is accurate, meets CMS quality standards, and results in program payments to providers which are in accordance with Medicare law, regulations and program instructions. I.11 Cost reports are scoped and selected for audit or settled without audit. Audit plans are approved by the Audit & Reimbursement (A&R) Business Function Lead and adhere to CMS guidelines and instructions. I.12 The contractor’s audit process is conducted in accordance with CMS manual instructions and timelines, 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 Communications of audit programs, desk review programs, CMS audit and reimbursement policies, and other audit related instructions are timely and accurately communicated to all appropriate audit staff. I.14 The contractor’s audit staff maintains its necessary knowledge and skills by completing continuing education and training (CET) required by CMS instructions, and documentation is maintained to support compliance by each staff member. 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 – Control Number Control Objective – Provider Audit 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 Notices of CAP Determination Letter are issued accurately and timely to Hospices and include all related documentation. End Section 50.9 – I Controls – Provider Audit: Back to Table of Contents