Attachment_A_-_Statement_of_Work.docx

STATEMENT OF WORK (SOW)

THE GRADUATE MEDICAL EDUCATION FULL-TIME EQUIVALENT RESIDENT ASSESSMENT

June 20, 2017

I. BACKGROUND

A. Program Authority The Children's Hospitals Graduate Medical Education (CHGME) Program and the Teaching Health Center Graduate Medical Education (THCGME) Program provide federal funds to support graduate medical education (GME) programs that train medical and dental residents. Specifically, the CHGME Program helps freestanding children’s hospitals to maintain programs that train residents in pediatric, pediatric subspecialty and non-pediatric programs. The THCGME Program promotes training for primary care residents (including residents in family medicine, internal medicine, pediatrics, internal medicine pediatrics, obstetrics and gynecology, psychiatry, general dentistry, pediatric dentistry, and geriatrics) in community based ambulatory patient care settings. GME follows graduation from medical and dental school and can take between three and seven years to complete, depending on the medical or dental specialty track chosen.

In 1999, Congress passed the Healthcare Research and Quality Act, which established the CHGME Program. The CHGME Support Reauthorization Act of 2013, enacted by Public Law 113–98, reauthorized the CHGME Program through fiscal year 2018, and included a provision to allow newly-qualified hospitals to apply for CHGME funding. The THCGME Program, Section 340H of the Public Health Service (PHS) Act, was established by Section 5508 of Public Law 111–148. Public Law 114–10, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), provided additional funding for the THCGME Program. See Appendix A: Governing Federal Statutes.

B. Audit Authority As required by legislative mandate, the full-time equivalent (FTE) resident assessment shall determine any changes to the FTE resident counts initially reported to the CHGME and THCGME Programs. This requirement is met in lieu of the Office of Management and Budget A-133 Requirement.

The audit of CHGME Program participating children’s hospitals is driven by Section 340E(e)(3) of the Public Health Service Act as amended, which states “the Secretary shall determine any changes to the number of residents reported by a hospital in the (initial) application of the hospital for the current fiscal year for both direct expense and indirect expense amounts.” This implies that, prior to the end of the federal fiscal year for which children’s hospitals have applied for CHGME Program funding, the Secretary must determine (reconcile) any changes to the FTE resident counts reported by a hospital in its initial application for the current fiscal year.

Similarly, the THCGME Program payments are prospective payments, and the statute provides for a reconciliation process through which overpayments may be recouped and underpayments may be adjusted at the end of the fiscal year. The Statute states that the Secretary shall determine any changes to the number of residents reported by a Teaching Health Center in the request to Health Resources and Services Administration (HRSA) for the current fiscal year, to determine the final amount payable to the Teaching Health Center for both direct expense and indirect expense amounts. Based on such determination, the Secretary shall recoup any overpayments made to pay any balance due to the extent possible.

The intent of the FTE resident assessments is not to replace the work conducted by auditors on behalf of the Medicare program, but to use such Medicare audit results and build on them. The final payment amounts are based on the FTE resident counts determined through such audits for the CHGME and THCGME Programs. These payments are considered a final intermediary determination for the purposes of section 1878 of the Social Security Act and shall be subject to administrative and judicial review under that section in the same manner as the amount of payment under section 1186(d) of such Act is subject to review under such section.

The children’s hospitals and teaching health centers participating in the CHGME and THCGME Programs have a large number of GME programs and residents being trained. There are currently fifty-eight children’s hospitals participating in the CHGME Program, sponsoring more than 500 GME programs and training more than 5,500 FTE residents. The THCGME program funded fifty-nine teaching health centers that are expected to train over 700 residents by the end of fiscal year 2017.

In accordance with Section 1886 of the Social Security Act, the Contractor shall assess the FTE resident counts and additional supporting documentation provided by the providers for all relevant cost report periods. The Contractor shall complete the FTE resident assessments within the following time periods, to allow the GME Programs to reconcile payments: For the CHGME Program, the FTE resident assessments shall commence on October 1 of each contract year and conclude no later than March 15. For the THCGME Program, taking place in option years one and four of the contract, FTE resident assessments shall commence on Aug 15 of each required contract year and conclude no later than November 15.

In particular, the six-month time frame for the CHGME Program significantly differs from the Medicare program, which provides for the resolution of data (including FTE resident counts) for a given Medicare cost report period to occur over several years following the hospital’s filing of the report. Medicare cost reports (MCRs) are used to report expenses and FTE resident counts for different types of Medicare reimbursable facilities, including children’s hospitals. Unlike the Medicare program, any changes to data reported by participating children’s hospitals to the CHGME Program (including FTE resident counts) affects the distribution of funding among all children’s hospitals participating in the CHGME Program.

In addition, only about two-thirds of the children’s hospitals participating in the CHGME Program filed full MCRs (i.e., report residents to Medicare on CMS 2552-10, Worksheet E-4); the remaining one-third filed low- or no-utilization MCRs or a combination of full and low- or no-utilization MCRs for all applicable years. Hence, it is imperative that inconsistencies and/or discrepancies related to the children’s hospitals FTE resident counts must be resolved within this six-month period to allow for adjustment of CHGME Program payments to the participating children’s hospitals prior to the end of the fiscal year.

HRSA has the appropriate systems in place to prevent duplicate payments by federal agencies. Therefore, the audit process requires auditors with knowledge and expertise in the graduate medical education-related laws and regulations that guide the GME Programs and their participating providers.

The contractor shall follow an FTE resident audit methodology designed to eliminate redundancies and streamline the process to cut costs. For example, CHGME auditors shall check with the CMS Medicare Administrative Contractor (MAC) as to whether an audit was conducted. The Contractor shall proceed with the audit if the FTE resident counts were never audited by either HRSA or CMS, or if the number of FTEs were not accurately assessed during prior audit.

A MAC is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims or Durable Medical Equipment claims for Medicare Fee-For-Service beneficiaries. One of the MAC’s responsibilities is to audit the FTE residents claimed by hospitals for reimbursement from CMS. The FTE residents are reported on the MCR, which is submitted to the MAC. The Contractor shall perform FTE resident audits on children’s hospitals and teaching health centers (THCs) requesting payment from HRSA for graduate medical education-related expenses. Therefore, the MAC is the CMS counterpart to the HRSA FTE resident assessment Contractor.

The assessment results impact final payments as required by law. In addition, the FTE resident audit results completed under this contract will be available to CMS auditors, to accurately assess the number of FTE resident counts that will be: 1) included in the Medicare Cost Report for those children’s hospitals that receive funding from CMS, and 2) excluded in the Medicare Cost Report for those hospitals affiliated with THC training that also receive funding from CMS. If the providers do not agree with the audit findings, they have the right to appeal the results to the Provider Reimbursement Review Board.

II. PURPOSE

The purpose of the audits is to ensure that appropriate regulations, program policies and guidelines are followed in determining which residents are eligible to be claimed for GME funding provided by the GME Programs.

III. PERIOD AND PLACE OF PERFORMANCE

The period of performance shall be one (1) 12-month base period plus four (4) 12-month option periods. The primary place of performance shall be at the Contractor’s facility.

IV. TASKS

Task 1.1: Kickoff Meeting The Contractor shall meet with the Contracting Officer's Representatives (COR) via conference call within five (5) business days of the Effective Date of Contract (EDOC).

Task 1.1.1 The Contractor shall prepare and send (via email) a written agenda for the kickoff meeting to the COR within two (2) business days of the EDOC. The agenda shall include the following:

· The Contractor’s proposal for audit, including the following items:

· The logistics of the review process to be performed;

· The key personnel in charge of project;

· The names of various contract personnel (staffing);

· Methodology for assessment of FTE resident counts;

· Finalized procedure for assessment of FTE residents; and

· Time frame for accomplishing the activities.

· Reporting requirements, including format of deliverables and submission dates;

· Review of timelines;

· Plan for Contractor coordination and communications with the COR; and

· Any questions from the Contractor.

Task 1.1.2 The Contractor shall provide minutes of the meeting within five (5) business days following the call with a summary of the topics discussed and the action items for both the Contractor and the COR.

CHGME PROGRAM

Task 1.2: CHGME Methodology Report

Task 1.2.1 Methodology Report Development (Base Year) The Contractor shall submit a draft CHGME Methodology Report for the base year to the COR via email within ten (10) business days of the EDOC. The Contractor shall develop a methodology report which takes into consideration the general methodology designed and implemented by Centers for Medicare and Medicaid Services (CMS) for auditing FTE resident counts claimed for Medicare payments, build upon work and data previously developed for Medicare and CHGME Program purposes, and have an established protocol to assure the coordination of effort and sharing of data between the CHGME Program, THCGME Program, and Medicare Program.

The Methodology Report shall include applicable statutory and programmatic information, and issues that affect FTE resident assessments or Medicare audits and may directly impact the FTE resident assessment of the CHGME Program. See Appendix B: Sample Methodology Report.

The COR will review the draft Report and provide comments to the Contractor. The Contractor shall incorporate the COR’s comments and submit a final CHGME Methodology Report to the COR via email within seven (7) business days of receipt of comments. The Contractor shall follow the audit processes detailed in the final CHGME Methodology Report to perform the FTE resident assessments.

Task 1.2.2 Methodology Report Update (Contract Years 1-4) The Contractor shall submit to the COR an updated CHGME Methodology Report in draft form reflecting any statutory changes, programmatic changes, and/or issues that arose during the FTE resident assessments or Medicare audits in the preceding 12-month period that may directly impact the FTE resident assessment. The Contractor shall submit the draft updated CHGME Methodology Report no later than 30 business days prior to the end of each contract year in the Base Year and Option Years 1-3.

The COR will review the updated Report and provide written comments to the Contractor. The Contractor shall incorporate the COR’s comments accordingly and return the CHGME Methodology Report to the COR for final approval within fifteen (15) business days of receipt of comments. The Contractor shall follow the audit processes detailed in the final updated CHGME Methodology Report to perform the FTE resident assessments.

Task 2: Execute CHGME FTE Resident Assessment The Contractor shall conduct the FTE resident assessment based on the approved methodology for auditing the FTE resident counts reported by providers participating in the CHGME Program, as detailed in the Methodology Report. The CHGME FTE resident assessments shall consist of three (3) levels (or types) of review (desk check, desk review, and field review), and the audit period shall occur October 1 – March 15 during each contract year.

The Contractor shall recommend the type or levels of review to conduct, which shall depend primarily on whether a review was previously conducted by another agency/entity or by HRSA for a particular cost report period. See Appendix D - G: Assessment Flowcharts.

The Contractor shall ensure that all supporting documentation and related FTE resident counts comply with CHGME Program and CMS requirements related to the documentation and counting of FTE residents as set forth in Section 1886 of the Social Security Act.

Task 2.1 Auditor Assignment Schedule The COR will provide the Contractor with a spreadsheet (Excel format via email) with the names, organization, and contact information for each CHGME participating hospital. The Contractor shall provide to the COR a spreadsheet (Excel format) with the names, organization, contact information, and hospital assignment(s) of all the auditors participating in the FTE resident assessment no later than five (5) business days from the date of the start of the desk checks and desk reviews, for each contract year.

Task 2.2 Introductory Letter

Task 2.2.1 The Contractor shall compose a draft CHGME Introductory Letter template, to include a formal request to the hospital for documentation to support resident FTEs claimed on the children’s hospital’s initial application. The CHGME Introductory Letter template shall include the name and contact information of the Contractor and a preliminary list of the information that will be required from the providers. The Contractor shall submit the draft CHGME Introductory Letter template to the COR via email within five (5) business days of the EDOC.

Task 2.2.2 The COR will provide comments related to the CHGME Introductory Letter template. The Contractor shall incorporate the COR’s comments and submit a final CHGME Introductory Letter template to the COR via email within three (3) business days of receipt of comments from the COR.

The Contractor shall submit a final introductory letter template to include:

· correct name, address, and provider number for the hospital;

· name and contact information of entity and the auditor assigned to do the assessment;

· confirmation of primary point of contact at the children’s hospital;

· dates and timeframes set by the Contractor (specific dates for submitting information helps ensure compliance and makes tracking and follow up easier);

· attachments identifying documents or data requested by the Contractor (any information that would identify a particular resident is not to be included in the body of the letter);

· identification of level of assessment completed in previous years by Contractors, such as desk check, desk review, or field review;

· identification of correct status for each MCR, if applicable.

Task 2.2.3 The Contractor shall send a CHGME introductory letter (via email) to all providers and the COR no later than ten (10) business days from the date of the start of the desk checks and desk reviews for each contract year. The Contractor shall send no more than fifty-two (52) copies of the introductory letter to the participating children’s hospitals.

Task 2.2.4 The Contractor shall submit a CHGME Introductory Letter status report to the COR via email within twenty (20) business days from the date of the start of the desk checks and desk reviews for each contract year. The CHGME Introductory Letter Status Report shall include the following:

· Name of the provider

· Contact information for assigned auditor

· Type of audit to be performed

· List of documentation requested

· Dateline given to provider

· List of documentation missing

Task 2.3 Desk Check The Contractor shall perform an estimated fifty-two (52) desk checks during each contract year on the children’s hospitals selected by the Program. Each desk check shall include assessment of three (3) years of provider cost report data: the 1996 cap year, prior year and penultimate year. The Contractor shall perform a desk check on MCRs that have been settled by the MAC and are not in the process of being reopened, and have previously been assessed by HRSA. The COR will provide the Contractor with access (electronically) to the initial applications, MCRs, and supporting documentation submitted by the CHGME participating hospitals no later than October 1 of each contract year. The Contractor shall assess the FTE resident counts reported in the initial application, MCRs and supporting documentation related to each provider participating in the CHGME Program following a methodology approved by the COR.

The Contractor shall request additional information related to the MCRs (including Intern and Resident Information System data) from the children’s hospital and/or the MAC. The assessment shall consist of comparing the FTE resident counts reflected in the most recent CHGME Program application (Form HRSA 99-1) to those reflected in the settled MCR, or the final resident assessment report from the previous application fiscal year.

Task 2.3.1 The Contractor shall prepare a summary report if the FTE resident counts reported in the MCR (settled by MAC) and the CHGME Program application agree, and the Contractor assesses that the level of review performed by the MAC met CHMGE Program statutory requirements and policies. The report shall summarize the findings as provided in the MAC’s work papers, to ensure all summary reports provided by Contractors are consistent with reports provided for all audit types performed.

Contractor shall perform the next level audit, referred to as a desk review and described in Task 2.4, if the FTE resident count on the settled MCR does not agree with the FTE resident count reflected in the CHGME Program application or there are questions related to the MAC’s work papers or the level of review conducted for Medicare purposes, then the MCR shall be reopened by the MAC as requested by the hospital and the Contractor.

Task 2.4 Desk Review The Contractor shall perform an estimated fifty-two (52) desk reviews during each contract year on the children’s hospitals selected by the Program. Each desk review shall include assessment of four (4) years of provider cost report data, where applicable: the 1996 cap year, the current year, prior year, and penultimate year. The Contractor shall review the MAC’s work papers to determine if the MCR was settled by the MAC without review. The Contractor shall conduct a desk review following consultation with and approval from the COR on: (1) MCRs that have been settled by the MAC and are in the process of being reopened (the Contractor shall only review the re-opened items as part of the desk review process); (2) MCRs that have not been settled by the MAC; (3) MCR periods that have not been previously assessed by HRSA; and (4) MCR periods previously assessed by HRSA with unresolved variances (e.g., desk check with unresolved variances), or as requested by a hospital filing a low- or no-utilization MCR. The Contractor shall review supporting documentation from the children’s hospitals for FTE resident count accuracy.

Task 2.4.1 The Contractor shall send an email to each participating children’s hospital detailing the supporting documentation requested as well as the deadline to submit supporting documentation for review. The Contractor shall include a deadline for the children’s hospitals of within ten (10) calendar days of receipt of the request from the Contractor. All documents will be delivered to the Contractor by children’s hospitals participating in the CHGME Program, as required by the CHGME Program audit authority. The Contractor shall begin each desk review with an assessment of supplied documentation to ensure acceptability for purposes of program review and completeness as necessary to determine FTE resident counts.

Task 2.4.2 The Contractor shall email the appropriate hospital representative acknowledging receipt of the requested supporting documentation within three (3) business days. The acknowledgment shall include a list of the documents received.

The Contractor shall notify the hospital when documentation is found to be incomplete or when information is irregularly reported. The Contractor shall notify the hospital of such deficiencies no later than ten (10) calendar days after the receipt of the documentation from the provider. The Contractor shall request a response from the hospital within five (5) calendar days. If the documentation, once revised, is still unacceptable, the Contractor shall notify the hospital (via email) within five (5) calendar days. The Contractor shall request a response with completed/revised documentation from the hospital within ten (10) calendar days

The Contractor shall submit to the COR a list (via email) of the hospitals that submitted and those that did not submit their documentation no later than November 15 for each contract year.

Task 2.4.3 The Contractor shall submit a written determination of whether any of the children’s hospitals participating in the CHGME Program have reported FTE residents that have also been claimed by the participating teaching health centers for the same period of residency training. The Contractor shall submit this written determination (via email) to the COR no later than Feb 21 of each contract year.

Task 2.5 Field Review The Contractor shall perform an estimated six (6) field reviews during each contract year. A field review is an FTE resident assessment conducted on the hospital site that focuses primarily on issues that could not be resolved during a desk check and/or desk review. The Contractor shall include assessment of four years of provider cost report data for each field review: the 1996 cap year, the current year, prior year, and penultimate year, if applicable. Field reviews for newly qualified CHGME-funded children’s hospitals shall commence on or after August 1 of the subject contract year and shall be completed by September 21 of the same contract year. The Contractor shall commence field reviews for previously funded CHGME children’s hospitals on or after November 1 of the subject contract year and shall complete the reviews by March 1 of the same contract year.

Task 2.5.1 The Contractor shall perform a field review for one of the following four situations: 1) the children’s hospital has an extremely large amount of documentation; 2) the children’s hospital has one or more specific trigger(s) identified in the previous year’s audit; 3) the children’s hospital has issues that cannot be resolved during the current year’s desk check, desk review, and/or desk review followed by the issuance of a management letter and technical assistance provided by the Contractor; or 4) the children’s hospital is newly qualified. The final selection of children’s hospitals to receive field reviews is determined by the COR.

For reference purposes, the first two types of field reviews will be referred to as a planned field reviews and the latter two types as responsive field reviews.

Task 2.5.2 The Contractor will be provided the CHGME initial application data reported by the newly qualified hospital(s) no later than two (2) business days following the initial application submission deadline.

The Contractor shall notify the COR (via email) of proposed travel for field reviews to determine eligibility for newly qualified hospitals, if requested, within three (3) business days from the date of approval by the COR

Task 2.5.3 The Contractor shall recommend which of the CHGME-funded children’s hospitals should receive planned field reviews, including a detailed list of the specific triggers for each hospital, by October 21 of each contract year. The Contractor shall propose which children’s hospitals should receive responsive field reviews, including a detailed list of the specific triggers for each hospital, within five (5) business days of identifying one or more specific triggers. The recommendation shall include the following: the hospital name, the specific trigger(s), estimated beginning and ending date of audit, and the cost estimate for additional labor and expenses needed to conduct the field review.

The Contractor shall determine the scope and level of the field review through close collaboration with the COR. The COR will approve or disapprove of each field review within five (5) business days of receipt of the field review recommendation from the Contractor. The COR may monitor the Contractor on field reviews. The Contractor shall notify the COR via email of proposed travel, for either planned or responsive field reviews, within fifteen (15) business days of the date of approval by the COR.

Task 2.5.4 The Contractor shall allow at least fifteen (15) business days between written notification (via email) of the hospital that it shall be subject to field review and commencement of the field review process. The Contractor shall agree upon any date of mutual choosing with the hospital. The Contractor shall perform the field review on-site at the hospital and affiliated institutions.

Task 2.5.5 The Contractor shall hold an entrance conference on-site at the start of each hospital’s approved field review. The Contractor shall establish administrative procedures and identify the contact person from the children’s hospital to obtain supporting documentation and information during the field review. The Contractor shall provide the notice of the time, place, and conference call-in information for all entrance conferences. The Contractor shall provide the COR with call-in information via email at least fifteen (15) business days prior to the call. The Contractor shall include a review of the materials requested when the hospital was informed of the field review. The COR and/or designated HRSA representative(s) may attend the entrance conference in person or via conference call.

Task 2.5.6 The Contractor shall include meetings with the hospital liaison and those responsible for the preparation of the documentation used in determination of FTE resident counts during the field review. The Contractor shall advise the hospitals to have the appropriate personnel present or accessible, provide a work area for the Contractor, advise the Contractor of work hours and building access, provide time frames for conducting the review, and provide the Contractor with appropriate contacts needed to perform the review. The Contractor shall ensure all objectives of the field review are met, and the review shall be cross-referenced to the CHGME Program application procedure and all conclusions shall be substantially supported.

Task 2.5.7 The Contractor shall conduct a final exit conference at the end of each hospital’s field review. The Contractor shall summarize the field review activities performed, explain any adjustments to the reported FTE resident counts, and answer any audit related questions from the children’s hospitals during the exit conference. The Contractor shall inform the COR via email within five (5) business days prior to the meeting of the time, place, and conference call-in information for all exit conferences. The COR will attend or participate via conference call in the exit conference.

Task 2.6 Audit Completion Procedures for Desk Check, Desk Review, and Field Review

Task 2.6.1 The Contractor shall examine all calculated fields relating to the determination of FTE resident counts based upon the supplied documentation for mathematical accuracy. The Contractor shall clarify discrepancies that are clearly mathematical in nature with the hospital’s representative, where appropriate, without further action once corrections and accompanying explanations are received in writing from the hospital’s authorizing official.

Task 2.6.2 The Contractor shall develop, examine, and resolve overlap reports generated by the Intern and Resident Information System (IRIS) based upon IRIS or IRIS proxy data provided by each hospital. In addition, the Contractor shall ensure the FTE residents claimed by the children’s hospitals are not also claimed by the teaching health centers participating in the THCGME Program for the same period of residency training time.

Task 2.6.3 The Contractor shall provide a determination of FTE resident assessments. In some cases, determination of FTE resident counts by the Contractor may differ from those reported in the initial application for CHGME Program funding by the participating children’s hospital. If it is determined that a hospital requires modifications of their FTE resident counts, the Contractor shall resolve such conflicts directly with hospital personnel responsible for application preparation and program administration.

Task 2.6.4 The Contractor shall provide the draft summary report (electronically) to each hospital and the COR, indicating the hospital-specific results of the FTE resident assessments, and indicate the status of all MCR periods reviewed for the reconciliation fiscal year under assessment within seven (7) business days of completion of the desk check, desk review, and/or field review for the same contract year. In preparing the draft summary report, the Contractor shall consider all discussions and evidence provided by the hospitals in reaching its final conclusions, and shall clearly identify adjustments, discuss potential adjustments in the FTE resident counts, and inform the hospital of the next steps in the review process and the time frame for responding to any proposed adjustments.

Task 2.6.5 The Contractor shall prepare the final FTE resident assessment report for each hospital that applied for CHGME funding upon completion of the desk check, desk review, and field review, which shall include a summary of the results of the audit and illustrate the individual findings of the review, the inclusion of the latest salient information obtained from the hospital, and references to the appropriate law(s), regulation(s), or manual source(s) that support the adjustments to the FTE resident counts or cap adjustments that may need to be incorporated into a hospital’s MCR. The Contractor shall include the following documents in the FTE resident assessment report (See Appendix C1 – Documentation Guidance; Appendix C2 – FTE Resident Assessment Report Exhibits):

· Cover Letter Signed by Project Director: This letter includes a brief description of the audit that was performed and for which years, as well as a list of the documents included for review by CHGME Payment Program.

· Conversation Record: This summary of the actions taken during the audit, including the sampling technique used during reviews and details of which exhibits were submitted.

· Exhibit O(1) - Contractor Assessment Summary (Adjustment): This form lists the reasons for any increases or decreases in resident FTE counts reported by the hospital and briefly explains the reason the adjustment occurred.

· Exhibit O(2) - CHGME HRSA 99-1 Application Form: This form compiles the resident FTE counts reported by the hospital, filed with CMS and audited by the Contractor.

· Exhibit P - Summary Sheet

· Exhibit P(1) - Contractor Adjustment Letter to the Hospital: This letter provides a summary of the resident FTE assessment findings to the respective children’s hospitals.

· Exhibit P(2) - CHGME Management Recommendation Letter to the Hospital: This letter is given to a hospital outlining certain conditions encountered during the audit and the recommended actions to avoid similar CHGME Payment Program assessment findings during future audits.

· Exhibit S - Final Medicare Administrative Contact (MAC) Letter/ “Top: This letter is sent from the Contractor to the MAC of each children’s hospital. This letter is to notify the MAC of the completion of the resident FTE assessment for each respective children’s hospital and to provide a summary report of the audit findings to be incorporated into the Medicare cost report, if applicable.

· Exhibit T - Reopening Request Letter to MAC: This letter requests the resident FTE assessment finding be incorporated into the Medicare process, where applicable.

· Exhibit T(1) - Reopening Request Letter to Contractor: This letter serves as a record for the Contractor of the request made to the MAC to incorporate resident FTE assessment findings into the Medicare process, where applicable.

· Exhibit 1 - Revised GME Affiliation Agreement(s) for an Aggregate Cap: This workpaper reconciles the GME Affiliation Agreement(s) and summarizes calculations that support final counts reflected in HRSA 99-1.

· Exhibit 2 - Summary of GME Affiliation Agreement: Revised GME Affiliation Agreement(s) for an Aggregate Cap, if available, as well as the email confirmation receipt to CMS and proof of submission to the Medicare MAC.

· Exhibit 3 – CMS 2552-10, Worksheet E-4: Medicare cost reports (MCRs) are used by the hospitals to report expenses and FTE resident counts. The Worksheet E-4 is the specific schedule within the MCR that is used to report the FTE counts for the hospital. The MCR is submitted by the hospital to the MAC for Medicare reimbursement and is also used by the CHGME and THCGME Programs for FTE counting and audit purposes. The MCRs should be accompanied by a report from CMS’s System for Tracking and Audit Reimbursement (STAR). The Contractor shall provide a STAR report to include: 1) the Medicare cost report status for the base, penultimate, prior and most recent years; and 2) the Notice of Program Reimbursement (NPR) date for each Medicare cost report period, if previously settled or resettled.

· Exhibit 4 - MMA letter from CMS, must be included if hospital claims MMA: This letter is a copy of the letter sent to the provider by CMS informing the hospital of an increase and/or reduction in the resident FTE cap due to Section 422 of MMA, Section 5503 and 5506 of the ACA, if applicable.

All application forms, supporting documentation and exhibits collected from CHGME participating hospitals and the contractor have received OMB approval (#0915-0247). Templates for several of the above-mentioned exhibits are provided by HRSA, all other required documents are submitted by the grantee or shall be developed by the Contractor as approved by HRSA (See Appendix C2 – FTE Resident Assessment Report Exhibits).

The Contractor shall provide one hospital-specific final FTE resident assessment report prepared for each children’s hospital summarizing all desk check, desk review, and field review activities, the number of FTE residents assessed for each relevant MCR period, and hospital-specific recommendations to improve the process in future assessments.

Task 2.6.6 The Contractor shall submit (electronically) all summary and final FTE resident assessment reports for desk checks and desk reviews to the COR for examination and concurrence, on an interim basis as the desk checks and desk reviews are completed but no later than February 1 of each contract year or within fifteen (15) business days of the audit completion, whichever is earlier.

Task 2.6.7 The Contractor shall submit (electronically) all summary, final FTE resident assessment reports, and conference reports (comprising details of the Entrance, Exit, and Final conferences) for field reviews to the COR for examination and concurrence, on an interim basis as the field reviews are completed but no later than March 15 of each contract year or within fifteen (15) business days of field reviews completion, whichever is earlier. All related resident assessment reports shall also be completed by this date.

Task 2.6.8 The Contractor shall include all summary reports which shall include a detailed explanation of the sampling methodology used to audit the FTE resident counts for each children hospital reviewed.

Task 2.6.9 The Contractor shall notify the children’s hospital’s MAC, where applicable, of the results of the FTE resident assessment. The MAC notification shall include, at a minimum, a detailed summary of findings (by MCR period) and any related adjustment reports or work papers that may be required to support the incorporation of the FTE resident assessment results into the Medicare system.

The Contractor shall submit all final reports to the COR for review and comment; final reports shall be subject to approval by the COR.

Task 2.7 Audit Support Activities For each type of review (i.e., desk check, desk review, and field review) the Contractor shall:

Task 2.7.1 ensure the work papers for each audit performed are: prepared in accordance with generally accepted Government auditing standards (GAGAS) (http://www.gao.gov/govaud/psu.htm); reviewed by a supervisor (by the Contractor); and include all adjustments identified during the review. The hospitals shall be advised by the Contractor of any proposed adjustments and given ten (10) business days to respond;

Task 2.7.2 include a protocol and/or procedures for addressing, processing and/or handling of appeals in accordance with Section 1878 of the Social Security Act as implemented at 42 CR 413.75 through 413.83 to the FTE resident assessment is subject to interpretation by the Contractor;

Task 2.7.3 participate in and provide support, where appropriate, in Medicare Provider Reimbursement Review Board (PRRB) proceedings related to the determination of FTE resident counts under the CHGME Program FTE resident assessment. Although every effort shall be made to resolve disputes prior to the release of the Contractor’s FTE resident assessment final report, hospitals dissatisfied with their final determination of FTE resident counts where the amount in controversy is greater than $10,000 may appeal to the PRRB.

A children’s hospital participating in the CHGME Payment Program has a statutory right to a PRRB review of a CHGME program determination for any federal fiscal year. A hospital may request a hearing by the PRRB as specified in §1878 of the Social Security Act (42 U.S.C. 1395oo), implemented by regulations found in 42 CFR Part 405, Subpart R.

A hospitals request for a PRRB hearing will be made in writing and postmarked within 10 business days of receipt of the Contractor’s determination. Upon notification from the PRRB that a request for a hearing has been filed, the Contractor shall contact CHGME Payment Program counsel and review the materials submitted by the children’s hospital within 10 days. Based on the findings of such review, the Contractor in consultation with CHGME Payment Program counsel shall join with the children’s hospital in written stipulations setting forth the issue in dispute. After these preliminary resolution discussions, should the issue remain in dispute, the Contractor and CHGME Payment Program counsel shall submit its position statement and any documents that support its position to the PRRB, with a copy to the provider, the COR and to the Contractor, by the date specified by the PRRB. Negotiations between the hospital and the CHGME Payment Program counsel may continue up until the time of the hearing.

A hearing will be conducted by the date specified by the PRRB. The parties to the hearing will be the Provider, who may appoint a representative, and the CHGME Payment Program, represented by its counsel. The parties may call witnesses to support their positions. This may include the Contractor as a witness for the CHGME Payment Program. Failure of any party to appear at the hearing without good cause shall result in dismissal of the case with prejudice.

The PRRB will render a written decision based on the conclusion of the hearing based on the record made at the hearing. A copy of the decision will be mailed to all parties at the hearing.

On June 25, 2004, CMS published a federal register notice (69 FR 35716), which established a closing date for incorporating hearing determinations by the PRRB for fiscal year payment purposes in the CHGME Payment Program. If the PRRB has not reached a decision by June 30th determining the actual number of full-time equivalent residents in a particular case, the departmentally overseen decision of the CHGME FI will stand. A PRRB decision after such date would be taken into account for payment determinations in the next fiscal year.

The decision of the PRRB will be final and binding upon all parties to the hearing before the PRRB. As the delegated authority to administer the CHGME Payment Program, the HRSA Administrator may affirm, reverse, or modify decisions of the PRRB brought under this program. The HRSA Administrator will follow procedures and regulations outlined in 42 CFR 1875, and as necessary, will work closely with CMS to ensure a uniform application of the laws;

Task 2.7.4 identify common or potential errors (e.g., overlaps, non-allowable FTE residents, part-time status, weighting, and non-provider/non-hospital settings) and provide a protocol for addressing and resolving such errors including errors affecting CHGME Program and non-CHGME Program participants;

Task 2.7.5 identify and address potentially problematic, fraudulent, or inappropriate determinations of FTE resident counts and, if applicable, refer them to COR (and/or CMS or the MAC when the hospital files full MCRs);

Task 2.7.6 ensure that the FTE resident counts reflected in form HRSA 99-1 of participating children’s hospitals’ applications for CHGME Program are consistent with all applicable guidance, rules and regulations governing the determination of FTE resident counts;

Task 2.7.7 ensure that children’s hospitals participating in the CHGME Program are held to the same standards (i.e., documentation requirements) irrespective of the independent auditor assigned to each participating hospital. This shall not preclude Contractors from requesting additional information or clarification from participating children’s hospitals on their FTE resident counts or supporting documentation; and

Task 2.7.8 address and incorporate new CMS-related or CHGME Program-specific statutory or programmatic changes affecting the assessment, documenting, or reporting of FTE residents into the FTE resident assessment.

THCGME PROGRAM (Optional Tasks 2.8 – 3.1.6)

Task 2.8: Methodology Report (Optional)

Task 2.8.1 Methodology Report Development The Contractor shall submit a draft THCGME Methodology Report for option year one to the COR via email within ten (10) business days of the beginning of option year one. The Methodology Report shall include applicable statutory and programmatic information and issues that affect FTE resident assessments of the THCGME Program. The Contractor shall consider the legislative and regulatory similarities and differences between the CHGME Program and the THCGME Program and incorporate this information in the THCGME methodology to audit those FTE residents trained by the THCGME Program.

The COR will provide comments related to the THCGME Methodology Report. The Contractor shall incorporate the COR’s comments and submit a final THCGME Methodology Report to the COR via email within seven (7) business days of receipt of comments. The Contractor shall follow the audit processes detailed in the final THCGME Methodology Report to perform the FTE resident assessments.

Task 2.8.2 Methodology Report Update The Contractor shall submit to the COR an updated THCGME Methodology Report in draft form reflecting any statutory changes, programmatic changes, and/or issues that arose during the FTE resident assessments that may directly impact the FTE resident assessment. The Contractor shall submit the draft updated THCGME Methodology Report no later than 30 business days prior to the end of option year three.

The COR will provide written comments related to the updated THCGME Methodology Report to the Contractor. The Contractor shall incorporate the COR’s comments accordingly and return the THCGME Methodology Report to the COR for final approval within fifteen (15) business days of receipt of comments. The Contractor shall follow the audit processes detailed in the final updated THCGME Methodology Report to perform the FTE resident assessments.

Task 2.9: Execute FTE Resident Assessment (Optional) The Contractor shall conduct the FTE resident assessment based on the approved methodology as detailed in the methodology report developed by the Contractor, for auditing the FTE resident counts reported by providers participating in the THCGME Program. The THCGME FTE resident assessments shall consist of two (2) levels (or types) of review (desk review and field review) and the audit period shall occur August 15 – November 15 during option year one and option year four.

The Contractor shall recommend the type or levels of review to be conducted, which shall depend primarily on whether a review was previously conducted by another agency/entity or by HRSA for a particular cost report period.

The Contractor shall ensure that all supporting documentation and related FTE resident counts comply with THCGME Program requirements related to the documentation and counting of FTE residents as set forth in Section 1886 of the Social Security Act.

Task 2.9.1 Auditor Assignment Schedule The Contractor shall assess the FTE resident counts and supporting documentation related to each provider participating in the THCGME Program following a methodology approved by the COR. The COR will provide the Contractor with a spreadsheet (Excel format via email) with the names, organization, and contact information for each THCGME participating teaching health center.

The Contractor shall provide to the COR a spreadsheet (Excel format) with the names, organization, contact information, and teaching health center assignment(s) of all the auditors participating in the FTE resident assessment, no later than five (5) business days from the date of the start of the desk reviews for each contract year, during option year one and option year four.

Task 2.9.2 Introductory Letter

Task 2.9.2.1 The Contractor shall compose a draft THCGME Introductory Letter template to include a formal request to the teaching health center for documentation to support resident FTEs claimed on the teaching health center’s application. The Contractor shall include in the THCGME Introductory Letter template the name and contact information of the Contractor and a preliminary list of the information that shall be required from the providers and affiliated hospitals. The Contractor shall submit the draft THCGME Introductory Letter template to the COR via email within five (5) business days of the contract year for option year one.

Task 2.9.2.2 The COR will provide comments related to the THCGME Introductory Letter template. The Contractor shall incorporate the COR’s comments and submit a final THCGME Introductory Letter template to the COR via email within three (3) business days of receipt of comments from the COR.

The Contractor shall submit a final THCGME introductory letter template to include:

· correct name, address, and provider number for the teaching health center;

· name and contact information of entity and the auditor assigned to do the assessment;

· confirmation of primary point of contact at the teaching health center;

· dates and timeframes set by the Contractor (specific dates for submitting information helps ensure compliance and makes tracking and follow up easier);

· attachments identifying documents or data requested by the Contractor (any information that would identify a particular resident is not to be included in the body of the letter);

· identification of level of assessment completed in previous years by Contractors, such as desk check, desk review, or field review;

· identification of correct status for each MCR, if applicable.

Task 2.9.2.3 The Contractor shall send an introductory letter (via email) to all providers, the affiliated hospitals associated with the teaching health centers, and the COR, no later than ten (10) business days from the date of the start of the desk reviews for each contract year during option year one and option year four. The Contractor shall send no more than forty-four (44) copies of the introductory letter to the participating teaching health centers.

Task 2.9.2.4 The Contractor shall submit an Introductory Letter status report to the COR via email within twenty (20) business days from the date of the start of the desk checks and desk reviews for each contract year during option year one and option year four. The Introductory Letter Status Report shall include the following:

· Name of the provider

· Contact information for…