CMS Pub. 100-06, ch. 8, § 40

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.