Medicaid Rate Setting Audit and Validation

Current and proposed rules from the Centers for Medicare and Medicaid Services (CMS) have caused state Medicaid agencies to rethink their approach to validating the method by which provider rates are determined and set. State budget pressures further exacerbate the need for state Medicaid agencies to accurately reimburse providers, protect current funds, and prevent audit findings and paybacks.

PCG Health™ has more than 20 years of experience working with publicly operated facilities and other provider reimbursement cost report data. PCG Health™ has detailed knowledge of cost reporting and rate setting practices of Medicaid agencies across the nation. We also have current knowledge of CMS rate setting preferences across the spectrum of providers and can work with Medicaid programs to tighten controls on current rate setting techniques.

Medicaid reimbursement techniques for providers such as inpatient and outpatient hospitals rely heavily on accurate cost reporting support and documentation. Heightened scrutiny by the Office of the Inspector General (OIG) and CMS increases state Medicaid agencies’ need for external review protocols that prevent future audit findings. PCG Health provides experienced resources to audit cost reports and payment calculations to ensure payments are in compliance with state and federal rules and regulations for:

• Fee-for-service rate setting;
• Cost reporting/cost settlement procedures;
• Disproportionate share hospital (DSH) claiming;
• Upper Payment Limits (UPL) compliance;
• Provider tax verification.

School-based health service providers and local public health and mental health agency providers are among the entities that have been targeted by new CMS rules that obligate state Medicaid programs to ensure actual payments do not exceed the cost of these services requiring the use of a standardized cost report. PCG Health can ensure compliance with the new CMS rules including:

• Allowable cost justification;
• Integrated time study result validation;
• Medicaid Eligibility Rate (MER) determination;
• Interim payment / interim rate calculation;
• Cost settlement confirmation.

PCG Health can also help state Medicaid programs audit other providers, including skilled nursing facilities, university affiliate physician practice plans, and other public providers operated by a “unit of government” affected by the new CMS rules.

Experienced PCG Health consultants understand and can apply the latest techniques for cost allocation to ensure optimal and compliant reimbursement to all provider types. 

Contact PCG Health to learn more about how our Medicaid rate setting audit and validation services can benefit your agency.