Medical Audit Services

The vendor required to provide medical audit services to ensure cost reports and other submitted data of providers are accurate and reasonable in accordance with reimbursement requirements and guidance set forth in the state plan and authoritative sources.
- The following general requirements in each audit service:
•    Providers have implemented and utilized financial, administrative, and internal control procedures to discharge their cost reporting responsibilities under the state plan and title regulations.
•    Determine through cost sampling, AICPA standard procedures, or other authoritative guidance whether the costs incurred and claimed are allowable under the state plan and to recommend adjustments based on tests of reliability and allowability.
•    Provide its findings as to whether the providers’ cost reports present a fair basis for reimbursement for services rendered in conformity with the state plan and title regulations and whether the providers’ cost reports are prepared on a consistent basis from one period to the next.
•    The accuracy and reasonableness of all such information obtained by examining the records and other supporting evidence, to the extent necessary to prepare an authoritative, objective report.
•    Report and make recommendations concerning the detection and correction of all improper, unallowable, or unusual costs to the district.
•    Audit providers, as ordered by the district, in accordance with the audit requirements contained in the state plan and title 29 regulations.
•    Maintain and organize working papers in a manner agreeable to both the district and the contractor and maintain all data, material and working papers in a location with convenient access to the district.
•    Perform audit services of the following types of private providers:
o    Nursing facilities
o    Hospitals
o    Intermediate care facilities for individuals with intellectual disabilities (ICFIID)
o    Child and adolescent supplemental security income program (CASSIP)
o    Healthy families program managed care organizations
o    Alliance managed care organizations
o    Immigrant children’s managed care organizations
o    Dual eligible special needs managed care organizations
o    Disproportionate share hospitals (DSH) receiving distributions
o    Federally qualified health centers
o    Home health agencies
o    Providers providing services pursuant to authority under authority of §1115 and §1915(c) of the social security act.