CMS Pub. 100-06, ch. 7, § 50.9

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