Provider Audit Contractors Medicare Administrative Contractors - Cost Report Audit & Reimbursement

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Laurence Watts
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Provider Audit Contractors Medicare Administrative Contractors - Cost Report Audit & Reimbursement AHLA Institute on Medicare and Medicaid Payment Issues March 26, 2014 Mark Korpela CMS, Office of

1 Provider Audit Contractors Medicare Administrative Contractors - Cost Report Audit & Reimbursement AHLA Institute on Medicare and Medicaid Payment Issues March 26, 2014 Mark Korpela CMS, Office of Financial Management, Division of Provider Audit Operations mark.korpela@cms.hhs.gov Overview of Presentation General Overview of Medicare Administrative Contractors (MACs) Medicare Cost Report Process Audit and Reimbursement Functions Audits of Electronic Health Record Incentive Payments - Hospitals March 26,

2 Background of MACs Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003 mandated that Part A fiscal intermediaries (FIs) and Part B carriers be replaced with MACs All FIs and Carriers have been transitioned to MACs MACs handle Medicare fee-for-service operations, including: Claims Processing Appeals Medical Review Medicare Secondary Payments Provider Enrollment Medicare Cost Report Audit and Reimbursement March 26, Background of MACs Currently 12 MAC Contracts 4 Include Home Health and Hospice Claims Processing 4 Additional Durable Medical Equipment (DME) MACs Important Acronyms CMS Staff CO Contracting Officer COR Contracting Officer Representative BFL Business Function Lead TM Technical Monitor March 26,

3 Background of MACs MAC contracts are subject to Federal Acquisition Regulations (FAR) 5 year contracts Base Year plus 4 Option Years CMS Communication with MACs Statement of Work (SOW) contract requirements Change Requests (CRs) formal instructions that may alter existing business processes or system functions. Technical Direction Letters (TDLs) clarify existing instructions or SOW requirements, make announcements, request information, etc. March 26, Provider Assignment with MACs Generally, a provider is assigned to the MAC that covers the state where the provider is located. Exceptions Qualified Chain Providers may elect to bill one MAC Specific rules not just a Home Office Provider may be out of jurisdiction but hasn t been moved yet. It will move eventually. Example J5 WPS still contains many out of jurisdiction providers Mutual of Omaha Specialty Providers and Demonstrations Home Health and Hospice Regional MACs (previously RHHIs) March 26,

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5 Medicare Cost Report Audit and Reimbursement Handled mainly by MACs Audit work also completed by a Program Safeguard Contractor (PSC) Cahaba Safeguard Administrators Special Projects Assist with audit and appeal backlogs MAC Transitions March 26, Medicare Cost Report Audit and Reimbursement Cost Report Processes Provider files the Cost Report MAC Acceptance Process Cost Report file sent to HCRIS Tentative Settlement Interim Rate Setting Amended Cost Reports follow similar process March 26,

6 Medicare Cost Report Audit and Reimbursement Audit Processes Desk Review established process to review cost report data and determine issues for audit. Risk Assessment Tool Adjustments to the Cost Report may be made during this process Audit review of specific cost report issues Onsite or Field Audit In-House Audit Wage Index Audit March 26, Medicare Cost Report Audit and Reimbursement Upon Completion of Audit Work Audit adjustments shared with provider for review Exit Conference Notice of Program Reimbursement (NPR) issued Payment made to provider, or demanded from provider Generally. Cost reports settled without audit NPR will be issued with 12 months of cost report acceptance. Cost reports selected for audit NPR will be issued within 60 days after the exit conference. March 26,

7 Medicare Cost Report Audit and Reimbursement After Issuance of the NPR Appeal PRRB or MAC (formerly Intermediary Appeal) Reopening requested by provider, or initiated by the MAC Interim Rates may be adjusted March 26, Electronic Health Record (EHR) Incentive Payments - HITECH Initial payments are calculated using the data entered by the MACs into the HITECH system (National Level Repository) Subsection (d) Hospitals (acute care) payment is based on a formula. $2M base. MACs enter data from latest filed cost report (data may be adjusted by MAC if needed). Critical Access Hospitals (CAHs) payment is based on actual cost incurred for certified EHR technology MACs review documentation submitted by the CAH after attestation, in order to determine allowable amount. Data is then entered into the system. March 26,

8 Electronic Health Record (EHR) Incentive Payments HITECH Final incentive payment is determined based on data from the cost report that begins during the HITECH payment year. MACs may review/audit the data used in the incentive payment. May be completed as part of the regular cost report audit, or separate. EHR Incentive Payments are not made by the MACs Separate contractor Payment File Development Contractor (PFDC) NGS Overpayments will also be demanded by PFDC Appeal Rights March 26, Electronic Health Record (EHR) Incentive Payments HITECH Meaningful Use Audits Completed by a separate contractor Figliozzi and Company States may also conduct reviews Contractor will audit the Meaningful Use attestation data to verify that the provider meets the criteria. If provider does not meet the criteria, entire payment for that year is demanded. Appeal Rights. March 26,

Surviving a CMS EHR Audit

Why Me? Surviving a CMS EHR Audit Gerald E Meltzer, MD MSHA Medical Director imedicware ASOA 2014 Providers who receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program