Assisting Medicaid Programs with Hospital Payment and Compliance

Hospitals represent one of the largest expenditure categories for Medicaid programs. We partner with our federal and state clients to assist them with managing these complex programs. We have experience in hospital audit, rate setting, reimbursement system design, and compliance monitoring. We have developed tools that make these complex processes more transparent and reliable. Our expertise includes: disproportionate share hospital (DSH) payment calculations and federally-mandated DSH audits, upper payment limit (UPL) compliance, reimbursement rate setting and payment methodology design and implementation, value-based purchasing (VBP) payment reforms, as well as supplemental payment programs and federal/state funding consulting. We have been assisting Medicaid programs with hospital payment and compliance projects for more than 40 years.

We provide the following services:

Audit and Attest

Read More

Bob Hicks, CPA


Myers and Stauffer’s audit teams understand the issues of importance to our federal and state clients with respect to hospitals. We have an in-depth understanding of both inpatient and outpatient hospital services, how costs are calculated for each of these services areas, and understand the unique operating environments affecting Medicare and Medicaid hospital payment systems. These include critical access hospitals, graduate medical education programs, DSH eligibility and payment, or numerous other considerations impacting hospital reimbursement and compliance.

Our audit teams have developed engagement tools to assist our government clients with achieving desirable audit outcomes within the hospital attest area. These tools help us to concurrently manage the flow of data efficiently, maintain HIPAA compliance, focus attest services on program risk areas, and help our clients foster good working relationships with their hospital program participants. Our hospital attest services include:

  • Cost report collection (CMS 2552 and/or Medicaid).
  • Web-based data exchanges for cost reports, supporting documentation, and related information.
  • Cost report database management, analytics, and reporting systems.
  • Audit and attest work programs and standardized work papers.
  • Inpatient and outpatient claims management and audit systems.
  • Attest protocols compliant with state and federal definitions.
  • Risk assessments to target audit work.
  • Training programs for clients, hospital providers, and other stakeholders.
  • DSH examinations:
    • Uncompensated care studies and analysis.
    • Hospital survey tools, data aggregation, and analysis systems.

Rate Setting and Reimbursement

Read More

Tim Guerrant, CPA


Our rate setting and reimbursement services address all aspects of hospital payment programs. Government-sponsored health care programs vary greatly in the methods for reimbursing inpatient and outpatient hospital services. We assist our government health care clients with a wide range of hospital payment methodologies and strategies, including inpatient diagnosis related group (DRG) systems, inpatient per diem or per discharge reimbursement, outpatient ambulatory payment classification (APC) and enhanced ambulatory payment groups (EAPG) systems, and outpatient per-service or bundled payment approaches. We help states with other hospital reimbursement issues including rate setting and reimbursement methodologies for specific services such as psychiatric, rehabilitation, or long-term acute care (LTAC) services, graduate medical education (GME) rates and payment pools, supplemental payment programs, and directed payments in a managed care environment. Our expertise includes:

  • Collecting and developing cost report databases.
  • Designing inpatient hospital reimbursement programs, including:
    • DRG grouper version.
    • Line item claim costing.
    • DRG relative weights.
    • Hospital base rates (statewide, peer group, hospital specific).
    • Outlier policy.
    • GME policy.
    • Provider training.
    • Workgroup participation.
    • Transfer and readmission payment policy.
  • Designing outpatient hospital reimbursement programs, including:
    • Outpatient billing requirements.
    • Line item costing methodology.
    • APC vs. EAPG.
    • EAPG weight setting.
    • Outpatient base rate (statewide, peer group, hospital specific).
    • Outlier policy.
    • Provider training.
    • Workgroup participation.
  • Developing payment rates and designing reimbursement methodologies for:
    • LTAC hospitals.
    • Psychiatric hospitals.
    • Rehabilitation hospitals.
    • Distinct part units within acute care hospitals.
    • Graduate medical education.
  • Developing supplemental payment programs.
  • Inpatient and outpatient cost settlement calculations.
  • Data analytics and dashboards:
    • Performance measures.
    • Improvement target goals.
    • Provider attribution.
    • Key performance indicators.

Medicaid Financing and Reporting

Read More

Tim Guerrant, CPA


We understand the financial constraints faced by Medicaid programs and offer services designed to maximize Medicaid financing streams while ensuring federal compliance is maintained. Our Medicaid financing professionals help state Medicaid agencies design and implement hospital payment programs and analyze state share funding solutions. We assist states in complying with federal regulations regarding limits on Medicaid payments, requirements pertaining to DSH payment calculations, and add on payments such as graduate medical education payments. Our professionals also support states in ensuring federal reporting processes are accurate and states are claiming federal funds to which they are entitled and not leaving federal funds unclaimed. Our Medicaid financing and reporting services include:

  • Inpatient and outpatient hospital supplemental payment program design, calculations, and distribution methodologies.
  • Certified public expenditures (CPE) programs:
    • Determining certified cost, obtaining provider certifications, reconciling CPE claims
      to cost data.
  • Inter-governmental transfer (IGT) arrangements.
  • Health care provider tax programs, including designing, data collection, implementing, and demonstrating compliance with broad based and uniformity requirements or waivers.
  • Fiscal and budget impact estimates.
  • Medicare UPL compliance.
  • GME payment calculations.
  • DSH payment programs:
    • DSH eligibility determinations.
    • DSH payment calculations and distribution methodology.

Delivery System and Payment Transformation

Read More

Jerry Dubberly, PharmD


Myers and Stauffer is an innovator assisting government-sponsored health care programs with the development of delivery system and payment transformation initiatives to improve access to integrated care models designed to improve the quality and efficiency of health care delivery. Our delivery system and payment transformation services include but are not limited to:

  • Stakeholder engagement.
  • Pursuit of federal authorities to accomplish programmatic objectives.
  • Integration of behavioral health and physical health.
  • Value-based contracting and alternative payment models.
  • Selection and use of quality measures.
  • Medicaid health homes.
  • Data analytics and dashboards:
    • Performance measures.
    • Improvement target goals.
    • Provider attribution.
    • Key performance indicators.

Legislation and Regulation

Read More

Tim Guerrant, CPA


Improving quality, outcomes, and patient experiences requires a fresh new perspective – a new way of thinking in an environment that has been traditionally under-funded and heavily utilized. We support our clients through the most significant period of change since the inception of the Medicare and Medicaid programs through services such as:

  • Analysis of programmatic and fiscal impact of proposed or passed legislation.
  • State plan amendment and administrative code drafting and consulting.
  • Regulation and policy development support.
  • Public hearing and workgroup participation.


Benefit/Program Integrity

Read More

Ryan Farrell, CFE


Through our benefit/program integrity services, Myers and Stauffer is able to assist our government health care clients with their review of hospitals to identify: improper payments; areas of non-compliance with applicable regulation and policy; investigation of potential fraud, waste, and abuse; and identification of payment system and policy weaknesses. Using cutting edge data analytics and subject matter expertise, our automated and complex reviews target areas such as: diagnosis and procedural coding, DRG validation, medical necessity, and adequacy of documentation. Myers and Stauffer also reviews hospital credit balances to determine monies owed back to the agency since Medicaid is the payor of last resort. Our program integrity services include:

  • Claims analysis.
  • Post-pay claims audits – clinical and financial.
  • Pre-pay claims audits – clinical and financial.
  • Medicaid recovery audit contractor (RAC) services.
  • Software modules for surveillance and utilization review subsystem (SURS), fraud and abuse detection services (FADS), and case tracking.
  • Provider compliance.
  • Payment system processing accuracy.
  • Fraud, waste, and abuse detection (FWAD) litigation support.
  • Electronic health record (EHR) incentive payment audits and consulting.

Litigation Support

Read More

Missy Parks, CFE, AHFI


Myers and Stauffer routinely serves as consultants for state Medicaid agency attorneys and state attorney general offices. Services to state Medicaid programs include preparing expert reports/depositions, participating as expert witnesses, and assisting with cross-examination of opposing expert witnesses. These cases may involve defending the state against lawsuits or supporting the state in legal actions against various patient-care providers and managed care entities. Services include:

  • Appeals/litigation support (testimony and administrative support).


Managed Care Oversight and Compliance

Read More

Mike Johnson, CPA, CFE

The extensive services offered by our highly skilled managed care team are generally focused on the oversight of health plans but can impact all provider types, including hospitals. Our services include:

  • Encounter data reconciliation and validation.
  • Financial audits, performance audits, and program effectiveness audits.
  • Network adequacy assessments and member access compliance.
  • Readiness reviews.
  • Claims payment and denial assessments, accuracy, and timeliness.
  • Medical record review.
  • Grievance and appeals analysis.
  • Contract compliance.
  • Other provider-specific issue review and resolution activities.