Post-Payment Audit Guidance

MEDICAID PATIENT VOLUME

Verifying Medicaid patient volume is a component of all AIU and MU post–payment audits. Medicaid patient volume is partially checked pre–payment, however a more in depth look into a provider´s Medicaid and non–Medicaid encounters is conducted in a post–payment audit. All Eligible Professionals (EPs) will need to meet the 30 percent Medicaid patient volume threshold with the exception of pediatricians who only need to meet 20 percent. Eligible Hospitals (EHs) will need to meet the 10% Medicaid patient volume threshold. During a post–payment audit, the provider must submit documentation replicating the attest–to Medicaid and non–Medicaid encounters during the 90 day reporting period.

When selected for a post–payment audit, the auditor will send an Excel spreadsheet to assist in supporting the provider´s Medicaid and non–Medicaid patient volume data. This spreadsheet may be completed and sent back to the auditor electronically. Please see a copy of this document in the following hyperlink: Medicaid Patient Volume Spreadsheet. Documentation from other auditable data sources may also be submitted to demonstrate a qualifying Medicaid patient volume. Additional information may be requested when the provider´s submitted Medicaid encounter data varies from the encounters found in the Medicaid Data Warehouse.

For Payment Year 2013 and beyond, the patient volume reporting period must be derived from any consecutive 90 day period within the calendar year prior to the payment year or preceding 12 month period from the date of the attestation. For payment years 2011–2012, the patient volume reporting period must be derived from any consecutive 90 day period within the calendar year prior to the payment year.

For additional information related to pre–payment patient volume please click here.