Audit and Reimbursement

This section will provide guidance on the Medicare cost report process, exception requests, and provider cost report appeals. Additionally, you will find access to several valuable educational resources and tools, designed to make your job easier.

Medicare Audit and Reimbursement Responsibilities

The primary function of the Medicare Audit and Reimbursement (MAR) Department is to

• determine a fair and equitable settlement of the provider’s cost report
• review/audit the provider’s cost report to ensure compliance with the principles of Medicare reimbursement, and
• determine a final settlement of the cost report.

These functions may take one of several forms; the review may take place in the offices of National Government Services or on site at the provider’s facility.

The Medicare Audit and Reimbursement Department processes cost report reopenings, exception requests, and provider cost report appeals. Provider appeals may be resolved either through administrative resolution, mediation, or by the Provider Reimbursement Review Board (PRRB).

The Medicare Audit and Reimbursement Department facilitates the following:

• Reviewing pass-through payments and rates
• Prospective payment system (PPS) rates
• Periodic Interim Payments (PIP), and
• Requests for extended repayment plans (ERP)
• Reviewing “As Filed” cost reports and determining tentative settlements
• Issuing retroactive lump sum adjustments to correct reimbursement
• Updating various payment limitations (e.g., TEFRA cost per discharge), and
• Disseminating the Provider Statistical & Reimbursement (PS&R) report on a timely basis and working with providers to resolve related issues

• The mailing address in Syracuse, New York for Audit and Reimbursement information, including cost report submissions, will remain the same. However, correspondence will now be addressed to NHIC, Corp, care-of National Government Services, Inc. The following is an example:

• New Lockboxes have been created for demand letters that were issued after cutover. The lockbox addresses for checks are as follows:

• Submission of check payments by Courier can be addressed as follows:

• Existing Practices and Procedures that did not change as part of the J14 transition:
• The NGS Cost Report Acceptance and Reimbursement Hub in Syracuse, NY will continue to process cost report acceptances, tentative settlements, and interim rate reviews. This process has been in place since 7/1/08.
• NGS Auditors in Portland, Manchester, & Lynnfield will be primarily responsibility for audits (both field and in-house), desk reviews, reopenings, and wage index desk reviews. However, NGS Audit and Reimbursement will utilize resources throughout the country.
• NGS associates in Portland, Maine will be primarily responsible for processing the appeals workload. However, NGS Audit and Reimbursement will utilize resources throughout the country.