Audit and Attest
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Federal, state, and local government health agencies reimburse health care providers and health plans billions of dollars annually for providing health care services to their most fragile populations. The audits employed by these organizations assist them in ensuring that those dollars are being used economically and to reimburse providers and health plans for the allowable costs of providing those services. Providing independent attest services to our clients provides the assurance that their limited resources are being distributed appropriately, while at the same time, providing the health care community with assurance they are being treated fairly in relation to their peers.

Our professionals are accountants and auditors who are highly trained and knowledgeable in the health care industry in areas including, but not limited to, claims, cost reports, state financial reports, the application of federal and state regulations, valuations, and asset tracing.

Our audit and attest experience includes these provider types:

Bob Hicks, CPA
Member
bhicks@mslc.com

816.945.5321

Medicare and State-Level Cost Reports

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As a national leader in audit services to state Medicaid agencies and to the Centers for Medicare & Medicaid Services (CMS), Myers and Stauffer processes nearly 10,000 cost reports annually. We offer a unique mix of qualifications in institutional and non-institutional provider reimbursement, analysis of health care costs and utilization, and investigation of fraud and abuse in cost reimbursed programs. These services include:

  • Web-based Medicaid and Medicare cost report collection and acceptability review.
  • Audit/attest work on Medicaid and Medicare cost reports.
  • Rate setting.
  • Risk assessments.
  • Analytics.
  • Database management.
  • Section 1115 waiver compliance.
  • Upper payment limits (UPL).
  • Appeals and litigation support.
  • CMS-approved certified public expenditure methodologies and reconciliations consulting.
  • Calculating the cost of managed care services for Medicaid.
  • Cost report review of local government entities that certify public expenditures, including providers of targeted case management, Medicaid administrative services, and emergency medical transportation.
  • Other consulting services.

Financial Component Audits

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Myers and Stauffer’s breadth of experience in performing audits of cost, and other financial and clinical data, goes beyond traditional cost reporting. Many state and federal agencies rely on our expertise in engagements that focus on specific elements of financial or clinical data which is often supplemental to cost reports, and the verification of the completeness and accuracy of that data for use in reimbursement. Our financial component audit services include:

  • Program or process cost verification.
  • Provider tax calculation and review.
  • UPL calculation and review.
  • Value-based purchasing performance payment calculation and review.
  • Minimum data set (MDS) assessment classification verification.
  • Quarterly case mix roster compilation.
  • Pharmacy invoice compilation and review.
  • Nursing hours audits.

Managed Care

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We perform audit and attest services of managed care organizations (MCO) on behalf of Medicare and state Medicaid programs. Our extensive federal and state experience places our firm in a unique position to ensure your programs are adhering to applicable guidance, criteria, and industry standards. These services include, but are not limited to:

  • Medical loss ratio examinations.
  • Administrative expense reviews.
  • Encounter data reconciliation and validation.
  • Readiness reviews.
  • Risk assessments.
  • Contract compliance reviews.
  • Network adequacy assessments.
  • Access to care reviews.
  • Performance audits.
  • Risk adjustment compliance reviews.
  • Benefit administration reviews.
  • Compliance program effectiveness audits.
  • Audits to address specific federal, state, or local government concerns.

Government Employee and Retiree Health Benefit Plans

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Our audits of third party administrators (TPAs) of government employee and retiree health benefit plans include testing of the TPA’s claims adjudication processes, clinical functions, internal audit functions, and compliance with contract terms and performance guarantees. Our services include:

  • Develop statistically valid claim sampling plan.
  • Perform testing of claims for various attributes such as proper payment according to the plan benefit design and the provider contract, correct accumulation of benefits, and proper coordination of benefits.
  • Perform testing of targeted claim samples such as duplicate claims, claims paid for excluded services, claims paid for employees or retirees not enrolled in the plan for the date of service, etc.
  • Analyze policies, procedures and processes surrounding clinical functions for gaps in comparison to state laws and regulations, contractual obligations, and industry standards.
  • Perform testing of clinical functions to ensure adherence to policies, procedures, and processes.
  • Analyze internal audit processes for gaps in comparison to contractual obligations and industry standards.
  • Analyze internal audit findings for payments that may be due to the governmental agency served.
  • Ensure compliance with contract terms.
  • Ensure compliance with performance guarantees and calculate damages that may be due.

Disproportionate Share Hospital (DSH) Audits

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No other firm possesses Myers and Stauffer’s combined DSH audit experience and the experience assisting Medicaid programs with DSH eligibility and payment calculations. Myers and Stauffer’s staff look beyond the DSH payment itself to understand and advise state clients on the interactions between waiver program uncompensated care pools, upper payment limit payments, financing, and DSH payments.

  • Annual independent DSH examination.
  • DSH payment calculations.
  • State plan amendments consulting.
  • Uncompensated care pool payment consulting.
  • Stakeholder training on Federal DSH audit requirements and audit process.
  • Appeal/litigation support for the state, as needed.
  • Assistance with CMS inquiries and audits.

As CMS issues additional guidance for DSH reporting and auditing requirements, we have created the following alerts:

January 2019

August 2019

September 2019

Benefit/Program Integrity

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Myers and Stauffer specializes in providing, risk assessment, error rate measurement, and specialized auditing services to support public health care and social service agencies. We are a client-focused, data-driven, value-oriented firm actively engaged in the environmental and regulatory challenges faced by our clients. Services include:

  • System and organization control audits.
  • Credit balance audits.
  • Eligibility audits.
  • Provider claims audits.

Promoting Interoperability (PI) Program

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Myers and Stauffer provides audit and consulting services to help states administer the Promoting Interoperability Program (formerly the Electronic Health Records (EHR) Incentive Program). We specialize in updating existing audit strategies by taking into account the state’s unique operations and the on-going changes to program requirements. In 2012, CMS made our audit strategy/guide available in an online toolkit as a benchmark for states to follow. Since that time, Myers and Stauffer has expanded our role and now provides pre-payment and post-payment services for states and are helping our clients develop strategies for the program’s 2021 sunset. As CMS looks to streamline multiple quality reporting programs into the new Merit-based Incentive Payment Systems (MIPS) and other Alternative Payment Models (APMs), we can help state’s explore options for the transition of the PI program in support of your state’s health information technology landscape. Our services include:

  • Develop pre-payment tools such as calculators to assist eligible hospitals (EHs) and eligible professionals (EPs) in determining whether they meet minimum eligibility requirements.
  • Conduct adopt, implement, upgrade (AIU) and meaningful use (MU) post-payment desk and on-site reviews for both EPs and EHs.
  • Perform EH aggregate Medicaid incentive payment post-payment desk reviews.
  • Review current program operations and make recommendations for appropriate audit coverage and/or audit strategy modifications.
  • Perform a risk assessment to select post-payment audits.
  • Perform pre-payment processing services for EPs and EHs, including security risk assessment (SRA) reviews.
  • Perform SWOT analyses to identify positive and negative factors within the State Medicaid Agency that promote or inhibit successful implementation of the program.
  • Design responses to and implement changes as a result of findings from HHS OIG audits.
  • Assist SMAs in preparing for CMS on-site visits and quarterly and annual reporting of audit findings to CMS.
  • Provide training and support to existing SMA staff.
  • Conduct provider audit preparedness outreach webinars.
  • Provide appeal support.

Pharmacy Audits

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Myers and Stauffer has been working with pharmacy data for more than 40 years. Our team of auditors and pharmacists has extensive experience auditing Medicaid, Medicare and state health plan pharmacy benefits. Our pharmacy audits include:

  • Pharmacy benefit manager (PBM) audits.
  • 340B consulting and auditing.
  • Procedure-coded drug/NDC-coded drug claim audits.
  • MCO pharmacy benefit contract compliance audits.
  • Medicaid drug rebate performance consulting and auditing.