Coordination With Audit and Reimbursement Staff

8.2.4 - Coordination With Audit and Reimbursement Staff (Rev. 670, Issued: 08-19-16, Effective: 11-23-16, Implementation: 11-23-16) MAC MR staff must work closely with their Audit/Reimbursement staff from the beginning of the postpayment process to ensure that the universe selected is appropriate and that overpayments and underpayments are accurately determined and reflected on the provider's cost report. They furnish the Audit/Reimbursement staff the following information upon completion of the postpayment review: • The sample documentation contained in Pub. 100-08, chapter 3, section 3.5.2; • The identification of incorrectly paid or incorrectly denied services; and • All other information required by the Cost Report Worksheets in Pub. 100-08, chapter 3, section 3.5.2 and applicable Exhibits. They also furnish the above information if adjustments are made as a result of appeals. In most instances, the Audit/Reimbursement staff will: • Determine the overpayment to be recovered based on MR findings and pursue the recovery of the overpayment; and • Use the information MR provides on their postpayment review findings to ensure an accurate settlement of the cost report and/or any adjustments to interim rates that may be necessary as a result of the MR findings. To preserve the integrity of Provider Statistical and Reimbursement Report (PS&R) data relative to paid claims and shared systems data relative to denied claims, and to ensure proper settlement of costs on provider cost reports, the same data must be used when the projection is made as was used when the sample was selected. Individual claims will not be adjusted. In the event that a cost report has been settled, Audit/Reimbursement staff will determine the impact on the settled cost report and the actions to be taken. Projections on denied services must be made for each discipline and revenue center when PPS is not the payment method. When notifying the provider of the review results for cost reimbursed services, MR must explain that the stated overpayment amount represents an interim payment adjustment. Indicate that subsequent adjustments may be made at cost report settlement to reflect final settled costs. Information from the completed Worksheets 1 - 7 must be routed to the Audit and Reimbursement staff. In addition to the actual and projected overpayment amounts, the information must provide the number of denied services (actual denied services plus projected denied services) for each discipline and the amounts of denied charges (actual denied amounts plus projected denied amounts) for supplies and drugs. Upon completion of the review, furnish the Audit and Reimbursement staff with the information listed in the Program Integrity Manual.