Planning and Management (Global Scoping)-Field and In-House

40 – Planning and Management (Global Scoping)-Field and In-House Audits (Rev. 107, Issued: 09-22-06; Effective: 10-01-06; Implementation: 10-02-06) The audit work plan and selection process is influenced by the budgetary restrictions imposed upon you by CMS. Annually, through the budget process and the Budget Performance Requirements (BPRs), CMS gives you guidance for managing audit resources in terms of areas of concentration and dollars available to accomplish the tasks. Develop an audit plan to identify cost reports to be audited and resources to be expended, taking into consideration the guidance that CMS gives you in §40.1 of this chapter and the BPRs about the types of providers or potential issues to be audited. However, do not use these priorities as the sole determining factor in the planning process. The planning process is based on your empirical knowledge, past performance of the provider, last time audited, and the relative risk associated with the settlement amount calculated from the cost report. Generally, select providers for audit that based on your professional judgment, represent the greatest risk for incorrect payment. Effective management of audit resources requires a continual decision-making process. As events occur throughout the audit cycle and circumstances come to light, the audit plan must be continually evaluated and priorities reassessed. If a greater audit requirement becomes evident, do not defer that audit work. Rather, defer or cancel audit work of lesser urgency. If there is no work of lesser urgency, seek guidance from the RO. Apply the appropriate level of resources for each audit to assure that payments made to a provider are not more or less than required under applicable law and regulations to achieve CMS's audit objectives. If you are unable to meet both the quantity and quality standards, seek guidance from your regional office (RO) on the extent to which you may deviate from your budget/plan while maintaining audit quality. You are expected to accomplish the goals outlined in the BPRs to the extent that other audit needs that are discovered during the year do not outweigh these goals. Use professional judgment to communicate workload adjustment needs to your RO. Monitor your progress on BPRs and discuss the impact of any problems that may develop in meeting the BPRs with your RO.