Audit Priority Considerations

40.2 – Audit Priority Considerations (Rev. 84, Issued: 11-16-05; Effective Date: 12-05-05; Implementation Date: 12-05- 05) One or more of the following audit priority considerations may enter into the process of formulating your audit plan. A – Significance of Total Medicare Program Payments In a PPS environment, direct specific attention to the following reimbursement areas or issues. • Bad debts. • Graduate medical education (GME). • Indirect medical education (IME). • Organ acquisition costs. • Disproportionate share hospital (DSH) payments. • Units excluded from inpatient PPS. • Allocations between PPS providers and cost-reimbursed subproviders. • Nursing/Allied Health passthrough payments. • Outlier payments. • Transitional corridor payments under the outpatient PPS (where applicable). B – Types of Providers Special attention may be required for certain types of providers because of known or anticipated problems or circumstances. Consider the following in your audit plan. • New providers. • Providers reimbursed on a cost basis (e.g., critical access hospitals, cancer hospitals). • End Stage Renal Disease Facilities need to be audited in accordance with the Balanced Budget Act requirements. The audit of End Stage Renal Dialysis Facilities to be performed for the three year cycle can be either a field audit or a desk audit • Providers receiving significant non-PPS payments. • Providers that were not audited recently. C – Conditions and Occurrences at the Provider • Change of ownership, termination, or change of provider type (e.g., critical access hospitals). • Cost report filed late without a satisfactory explanation. • Fraud and abuse investigations as directed by the Office of Inspector General (OIG) or Department of Justice (DOJ).