Current through February 27, 2024
(a) In
administering the Medicaid program, the department may perform facility audits,
desk reviews, and field audits of various types and scope and take the results
of those facility audits, desk reviews, and field audits into account in
establishing a facility's payment rate. The department will perform facility
audits, desk reviews, and field audits with respect to a facility's year-end
report submitted under
7
AAC 150.130(c). The scope and
frequency of facility audits, field audits, and desk reviews are determined at
the department's discretion. This section does not apply to the department's
conduct of investigations or audits regarding patient abuse or neglect, fraud,
or other program noncompliance. This section does not limit the department's
authority under this chapter to review and adjust items directly included in a
facility's payment rate based on a budget submitted under
7
AAC 150.130(b).
(b) If the department performs a field audit
or desk review, the process in this subsection applies. The department will
commence its field audit or desk review with respect to a facility's year-end
report after the facility has filed its year-end report under
7
AAC 150.130(c) and the department has
determined the report to be complete under
7
AAC 150.140(e). The department will
review the facility's year-end report and provide written notice in accordance
with 7 AAC 150.140(a) -
(d). The department will complete its field audit or desk review of a
facility's year-end report and provide to the facility a completed field audit
or desk review report. The department will provide to the facility, as
attachments to the department's completed report, a revised Medicare cost
report, and a revised Medicare cost report in electronic format if the facility
provided a CMS-approved electronic filing of its Medicare cost report with its
annual year-end report. The department will provide the department's completed
report and all attachments to the facility promptly upon completion, in
accordance with (1) or (2) of this subsection, or (f) of this section. The
following provisions apply to year-end field audit and desk review reports:
(1) if a facility's year-end report required
by 7 AAC 150.130(c)
is filed with the department no more than 150 days after the close of the
facility's fiscal year and is determined by the department to be complete, the
department will provide to the facility a completed report and the department's
proposed adjustments to the year-end report for purposes of setting rates under
this chapter no later than 40 days before the beginning of the facility's
applicable rate year;
(2) if the
facility's year-end report required by
7
AAC 150.130(c) is filed with the
department more than 150 days after the close of the facility's fiscal year,
the department may establish a temporary rate for the facility pending
establishment of the facility's permanent rate;
(3) a facility may file with the department a
response to the department's field audit or desk review report no more than 40
days after the date the department issues the report; the department may make
additional related adjustments if the facility makes objections to the
department's adjustments; the department will provide to the facility a
description of any additional adjustments;
(4) adjustments proposed during the course of
a desk review or a field audit are not limited to adjustments the department
has made in prior desk reviews or audits; the department may make adjustments
to reflect reporting in accordance with AS 47.07 and 7 AAC 105 - 7 AAC
160.
(c) The department
may conduct desk reviews or field audits of a facility. The department may
conduct a field audit with respect to a facility's year-end report submitted
under 7 AAC 150.130(c)
or expand the desk review to a field audit. During a department desk review or
field audit, the department may review a sample of medical and billing records
for both Medicaid and non-Medicaid patients in order to determine that the
Medicaid program is being charged no more than any other payer types for the
same services.
(d) The department
may limit its review of a facility to a desk review. The department is not
required to conduct a desk review in accordance with the auditing standards
applicable to field audits. As part of a desk review, the department may submit
requests for documents or production of other items, as well as requests for
information or responses to specific questions. A facility will be allowed at
least 15 days, but not more than 45 days, including extensions, to provide the
department with its response to the requests, as measured from the date that
the department mailed, sent by electronic mail, or otherwise forwarded the
requests to the facility. A facility's failure to timely respond to the
department's requests as provided for in this subsection may result in
permanent disallowance of the items in question. This section does not limit
the right of a facility to appeal adjustments under
7
AAC 150.220.
(e) The department may conduct a field audit
of a facility. The department's field audits will be conducted in accordance
with the Government Auditing Standards established by the
comptroller general of the United States, adopted by reference in
7
AAC 160.900. In conducting a field audit, the
following procedures govern:
(1) the
department will notify the facility at least 20 days in advance of any field
work scheduled at the facility; the notification will state the planned areas
of emphasis and describe documents, items, or other information that the
facility is required to produce at the entrance conference; this requirement
does not limit the department's authority to modify the audit or to require
additional information that the department considers necessary; the
notification will include a proposed agenda for the entrance
conference;
(2) the department will
schedule an entrance conference with the facility at the earliest practicable
time during the audit; at the entrance conference, the department may discuss
all proposed adjustments identified to date, will designate the auditor in
charge of conducting the audit on behalf of the department, and will address
necessary administrative issues relating to the audit; at the entrance
conference, the facility shall have all materials requested in the notification
of the field audit available for the auditor, designate the person who will act
as liaison on behalf of the facility for all purposes with respect to the
audit, address the availability of third parties involved in preparation of the
information being audited, and address other issues relating to the conduct of
the audit;
(3) the timelines
established for a facility's response to the department's requests for
documents and other information relating to desk reviews also apply to field
audits, except for requests made by the auditor while at the facility in the
conduct of a field audit; while the department is at a facility conducting a
field audit, the facility shall promptly respond to the auditor's requests to
produce documents or other items, and to requests for information during normal
working hours;
(4) the department
will work with the facility to schedule the auditor/facility liaison
consultations that are necessary to discuss proposed audit adjustments, open
issues, and general progress of the audit;
(5) an exit conference shall be conducted as
audit work at the facility nears completion unless the facility requests the
department in writing not to conduct an exit conference; the department's
auditor and the facility's representatives authorized to respond to audit
questions shall attend the exit conference; third-party preparers of reports or
statements subject to audit and other facility consultants may also attend an
exit conference; at an exit conference, the department will provide the
facility with all audit adjustments that have been made final by that time,
discuss unresolved issues, and indicate what type of information is required
from the facility to resolve those issues; the department may make additional
findings and adjustments during preparation of the audit report;
(6) a facility shall, no more than 30 days
after the date of the exit conference, provide documents or other items not
available at the exit conference and its comments relating to the department's
proposed audit adjustments; the auditor may, for good cause, extend the time
for the facility to provide the documents or other items;
(7) the department will review and consider
the information provided by the facility and issue the audit report and
adjustments that are proposed to be made for purposes of setting rates under
this chapter;
(8) a facility's
failure to timely respond to the department's requests as provided in this
subsection may result in permanent disallowance of the items in question; this
paragraph does not limit the right of a facility to appeal adjustments under
7
AAC 150.220.
(f) The department may conduct desk reviews
or field audits of a facility at times later than otherwise provided for in
this section. To the greatest extent practicable, the procedures described in
this section apply to out-of-time desk reviews and field audits. The department
may prospectively adjust a facility's rates or other payments, taking into
account the out-of-time desk review or field audit at the time of the
facility's next rate-setting for the rate year that begins at least 90 days
after the department provides the completed report to the facility. In
establishing a rate, the department is not required to consider or include
adjustments made by Medicare intermediaries to Medicare cost reports after the
department has completed its audit. The department will provide the facility
with all adjustments proposed to be made for purposes of setting rates under
this chapter and attachments specified in (b) of this section.
(g) The report presented to the facility will
include
(1) criteria that form the basis of
the adjustments, including the statutory, regulatory, or contractual bases of
the criteria;
(2) findings that
state the facility's noncompliance with applicable statutes, regulations, or
contractual requirements, and that state calculation or reporting
errors;
(3) a revised year-end
report if the report identifies changes that should be made in the year-end
report; and
(4) other findings as
determined by the department.
(h) A facility shall produce items to be
desk-reviewed or audited by the department at a location within the state or at
another place agreed upon by the department and the facility.
(i) For purposes of this section,
(1) "auditor" means the department's
officials, employees, contractors, agents, and any other person acting on the
department's behalf in conducting an audit of a facility;
(2) "desk review" means the department's
review that is conducted without the auditor visiting the facility being
desk-reviewed for the purpose of conducting tests or the initial phase of a
field audit;
(3) "facility" means
the same entities listed in the definition of "facility" in
7
AAC 160.990 and includes all of a facility's
affiliated or otherwise related persons that possess documents or other
information related to the entity that is subject to audits under this
section;
(4) "field audit" means
the department's audit that includes at least one facility visit by the auditor
for the purpose of conducting audit tests;
(5) "rate year" means the prospective payment
year of a facility, based upon that facility's fiscal year;
(6) "facility audit" means a systematic
inspection of accounting and statistical records of a facility, including
analyses, tests, and confirmations.
Authority:
AS
47.05.010
AS 47.07.070
AS 47.07.071
AS
47.07.074
