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Audit and Reimbursement

The primary functions of CGS Medicare Audit and Reimbursement Department are:

  • Assure final payments to providers are in accordance with Medicare laws, regulations, and instructions.
  • Verify financial and statistical information contained in the Medicare cost report.
  • Arrive at a correct program reimbursement. In so doing, preserve the provider's interests and rights but at the same time apply program policies to specific situations to ensure compliance with these policies.

The functions of Medicare Audit and Reimbursement are divided between three distinct areas:

Reimbursement

  • Contact Information
  • Review pass-through payments for Hospitals, RHCs, CORFs, Opts, FQHCs and CMHCs
  • Review Prospective payment system (PPS) rates
  • Review Periodic interim payments (PIP)
  • Determine tentative settlements for Hospitals, RHCs, CORFs, Opts, FQHCs and CMHCs
  • Review ESRD Low Volume Attestations
  • Review Exception Requests
  • Issue retroactive lump sum adjustments to correct reimbursement
  • Update various payment limitations (e.g., TEFRA cost per discharge)
  • Work with providers to resolve Provider Statistical and Reimbursement (PS&R) report related issues
  • Review Provider-based Determinations
  • Calculate Per Resident Amounts
  • Review of HITECH attestations

Audit

  • Contact information
  • Receipt and acceptance of Cost Reports for all provider types
  • Tentative settlement of SNF and ESRD cost reports
  • Desk Review and/or Audit of cost reports for all provider types
  • Review pass-thru payments for SNFs
  • Determine a final settlement of the cost report
  • Review Wage Index Data

Cost Report Reopening and Appeals

  • Contact information
  • Process reopening requests
  • Process cost report appeals

Reviewed: 09.02.15


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