J.1.d_Appendix_D_-_Extrapolation_Template.pdf

Plan:

Plan Year:

UNIVERSE STATISTICS

Instructions:

Complete the blue and green colored items in the following table for the population of claims/services to be sampled.

Figures shown in the template are for illustration only. Contractors will need to customize the following items to their particular Medicare cost plan universe:

Number of strata (column 1) - Each cost report cost center could be a stratum, and if so then the stratum limits (column 2) would be the cost center name and not min/max dollar values.

Also, if necessary certain cost centers could be further segregated into two or more strata by dollar values.

Stratum min/max limits (column 2) - If stratum are determined by dollar value, customize the minimum and maximum stratum limits to the appropriate amounts for the particular universe.

Green items (columns 4, 5, 6) should be input into RAT-STATS.

RAT-STATS will calculate the optimal number of items to sample per stratum (enter in column 7). However, this statistically valid sample amount may not attain the total sample size set by CMS.

In the fictional example below, only 215 items were included in the output from RAT-STATS, but the CMS sample size is 350.

The minimum stratum sample size (column 8) must be considered to ensure enough coverage for each stratum. CMS sampling guidance states that this minimum is 30 items per stratum.

The formula in column 9 determines whether the RAT-STATS output sample size met or exceeded the minimum stratum sample size. If 30 items was not met, the minimum of 30 is inserted.

Note: If the total stratum universe is less than 30 items, the Contractor will need to change the formulas in columns 8-10 of that stratum to reflect that all items will be tested (column 11 sample items = column 6 items in universe) and the suggested minimum of 30 items will not be met.

The formula in column 10 allocates the remaining required samples to the stratum based on the weighted value of the universe (column 3) so that the CMS minimum total sample size is met.

The allocation may need to be adjusted due to rounding. In the example, the total number of samples in column 11 is 351, not 350. The column 10 allocation would need to be tweaked.

The Contractor can also choose a different, rational method to allocate the remaining samples needed to get to the CMS total sample size.

1 3 4 5 6 7 8 9 10 11

Stratum Total Value of

Universe Standard Deviation Mean

Total # of Items in Universe

RAT-STATS

SVS Output

Minimum Stratum

Size Ratio

Allocation

Allocated Additional Samples

Total # of Items in Sample

1 $0.00 to $249.99 $41,038,006.25 enter enter 181,345 72 30 72 35 107 2 $250.00 to $999.99 $38,655,882.65 enter enter 19,827 57 30 57 33 90 3 $1,000.00 to $3,499.99 $24,667,061.46 enter enter 4,894 42 30 42 21 63 4 $3,500.00 to $14,999.99 $20,224,637.94 enter enter 1,281 27 30 30 17 47 5 $15,000.00 & up $16,126,998.43 enter enter 286 17 30 30 14 44

Total $140,712,586.73 207,633 215 150 231 120 351

Minimum CMS Total Sample 350

NOTE: According to Chapter 8, Section 4.2 of the Medicare Program Integrity Manual, "If a particular probability sample design is properly executed, i.e., defining the universe, the frame, the sampling units, using proper randomization, accurately measuring the variables of interest, and using the correct formulas for estimation, then assertions that the sample and its resulting estimates are “not statistically valid” cannot legitimately be made. In other words, a probability sample and its results are always “valid.” Because of differences in the choice of a design, the level of available resources, and the method of estimation, however, some procedures lead to higher precision (smaller confidence intervals) than other methods."

RAT-STATS Inputs for Variable SVS SVS Determination for Sample Selection

Stratum Limits

B7DV

Typewritten Text

B7DV

Typewritten Text Appendix D

AUDIT RESULTS

Instructions:

Complete the colored items in the following table for the population of claims/services to be sampled.

Green items will be input into RAT-STATS Note: Figures shown in the template are for illustration only.

Claim Identifiers Auditor Findings

Sample # Stratum # Claim # Other

Identifier Examined

Value Audited Value Difference

Value (e.g., line (e.g., actual (e.g., correct error number) paid amount) paid amount) amount

1 1 5555555 1 $58.26 $58.26 $0.00 2 1 5555556 1 $31.07 $31.07 $0.00 3 1 5555557 1 $22.15 $0.00 $22.15 4 1 5555558 1 $88.74 $88.74 $0.00 5 1 5555559 1 $7.52 $7.52 $0.00 6 1 5555560 1 $28.49 $28.49 $0.00 7 1 5555561 1 $56.00 $56.00 $0.00 8 1 5555562 1 $220.51 $220.51 $0.00 9 1 5555563 1 $48.70 $48.70 $0.00 10 1 5555564 1 $109.70 $109.70 $0.00 11 1 5555565 1 $0.00 $0.00 $0.00 12 1 5555566 1 $28.08 $28.08 $0.00 13 1 5555567 1 $44.37 $44.37 $0.00 14 1 5555568 1 $53.67 $53.67 $0.00 15 1 5555569 1 $113.90 $113.90 $0.00 16 1 5555570 1 $33.26 $33.26 $0.00 17 1 5555571 1 $111.90 $111.90 $0.00 18 1 5555572 1 $17.80 $17.80 $0.00 19 1 5555573 1 $0.00 $0.00 $0.00 20 1 5555574 1 $201.38 $150.00 $51.38 21 1 5555575 1 $17.75 $17.75 $0.00 22 1 5555576 1 $29.94 $29.94 $0.00 23 1 5555577 1 $89.92 $89.92 $0.00 24 1 5555578 1 $186.53 $186.53 $0.00 25 1 5555579 1 $58.26 $58.26 $0.00 26 1 5555580 1 $38.95 $38.95 $0.00 27 1 5555581 1 $0.00 $0.00 $0.00 28 1 5555582 1 $36.50 $36.50 $0.00 29 1 5555583 1 $67.15 $67.15 $0.00 30 1 5555584 1 $40.28 $40.28 $0.00 31 1 5555585 1 $16.50 $16.50 $0.00 32 1 5555586 1 $63.51 $63.51 $0.00 33 1 5555587 1 $49.64 $49.64 $0.00 34 1 5555588 1 $144.00 $144.00 $0.00 35 1 5555589 1 $28.55 $28.55 $0.00 36 1 5555590 1 $16.02 $16.02 $0.00 37 1 5555591 1 $49.51 $49.51 $0.00 38 1 5555592 1 $0.00 $0.00 $0.00 39 1 5555593 1 $30.00 $30.00 $0.00

Claim Identifiers Auditor Findings

Sample # Stratum # Claim # Other

Identifier Examined

Value Audited Value Difference

Value (e.g., line (e.g., actual (e.g., correct error number) paid amount) paid amount) amount

40 1 5555594 1 $26.27 $26.27 $0.00 41 1 5555595 1 $50.74 $50.74 $0.00 42 1 5555596 1 $100.76 $100.76 $0.00 43 1 5555597 1 $31.11 $31.11 $0.00 44 1 5555598 1 $1.66 $1.66 $0.00 45 1 5555599 1 $26.78 $26.78 $0.00 46 1 $0.00 47 1 $0.00 48 1 $0.00 49 1 $0.00 50 1 $0.00 51 1 $0.00 52 1 $0.00 53 1 $0.00 54 1 $0.00 55 1 $0.00 56 1 $0.00 57 1 $0.00 58 1 $0.00 59 1 $0.00 60 1 $0.00 61 1 $0.00 62 1 $0.00 63 1 $0.00 64 1 $0.00 65 1 $0.00 66 1 $0.00 67 1 $0.00 68 1 $0.00 69 1 $0.00 70 1 $0.00 71 1 $0.00 72 1 $0.00 73 1 $0.00 74 1 $0.00 75 1 $0.00 76 1 $0.00 77 1 $0.00 78 1 $0.00 79 1 $0.00 80 1 $0.00 81 1 $0.00 82 1 $0.00 83 1 $0.00 84 1 $0.00 85 1 $0.00 86 1 $0.00 87 1 $0.00

Other

Identifier Examined

Value Audited Value Difference

Value (e.g., line (e.g., actual (e.g., correct error number) paid amount) paid amount) amount

88 1 $0.00 89 1 $0.00 90 1 $0.00 91 1 $0.00 92 1 $0.00 93 1 $0.00 94 1 $0.00 95 1 $0.00 96 1 $0.00 97 1 $0.00 98 1 $0.00 99 1 $0.00 100 1 $0.00 101 1 $0.00 102 1 $0.00 103 1 $0.00 104 1 $0.00 105 1 $0.00 106 1 $0.00 107 1 $0.00 108 2 5555631 1 $380.00 $380.00 $0.00 109 2 5555632 1 $349.00 $349.00 $0.00 110 2 5555633 1 $288.48 $288.48 $0.00 111 2 5555634 1 $292.00 $292.00 $0.00 112 2 5555635 1 $873.40 $600.00 $273.40 113 2 5555636 1 $344.91 $344.91 $0.00 114 2 5555637 1 $266.25 $266.25 $0.00 115 2 5555638 1 $633.90 $633.90 $0.00 116 2 5555639 1 $256.00 $256.00 $0.00 117 2 5555640 1 $360.00 $360.00 $0.00 118 2 5555641 1 $375.00 $375.00 $0.00 119 2 5555642 1 $420.42 $420.42 $0.00 120 2 5555643 1 $707.25 $707.25 $0.00 121 2 5555644 1 $480.06 $480.06 $0.00 122 2 5555645 1 $349.12 $349.12 $0.00 123 2 5555646 1 $285.45 $285.45 $0.00 124 2 5555647 1 $700.00 $700.00 $0.00 125 2 5555648 1 $317.68 $317.68 $0.00 126 2 5555649 1 $310.10 $310.10 $0.00 127 2 5555650 1 $423.08 $423.08 $0.00 128 2 5555651 1 $827.75 $827.75 $0.00 129 2 5555652 1 $424.80 $424.80 $0.00 130 2 5555653 1 $274.25 $274.25 $0.00 131 2 5555654 1 $316.80 $316.80 $0.00 132 2 5555655 1 $551.93 $551.93 $0.00 133 2 5555656 1 $445.00 $445.00 $0.00 134 2 5555657 1 $420.30 $420.30 $0.00 135 2 5555658 1 $260.31 $260.31 $0.00

Other

Identifier Examined

Value Audited Value Difference

Value (e.g., line (e.g., actual (e.g., correct error number) paid amount) paid amount) amount

136 2 5555659 1 $561.47 $561.47 $0.00 137 2 5555660 1 $392.00 $392.00 $0.00 138 2 $0.00 139 2 $0.00 140 2 $0.00 141 2 $0.00 142 2 $0.00 143 2 $0.00 144 2 $0.00 145 2 $0.00 146 2 $0.00 147 2 $0.00 148 2 $0.00 149 2 $0.00 150 2 $0.00 151 2 $0.00 152 2 $0.00 153 2 $0.00 154 2 $0.00 155 2 $0.00 156 2 $0.00 157 2 $0.00 158 2 $0.00 159 2 $0.00 160 2 $0.00 161 2 $0.00 162 2 $0.00 163 2 $0.00 164 2 $0.00 165 2 $0.00 166 2 $0.00 167 2 $0.00 168 2 $0.00 169 2 $0.00 170 2 $0.00 171 2 $0.00 172 2 $0.00 173 2 $0.00 174 2 $0.00 175 2 $0.00 176 2 $0.00 177 2 $0.00 178 2 $0.00 179 2 $0.00 180 2 $0.00 181 2 $0.00 182 2 $0.00 183 2 $0.00

Other

Identifier Examined

Value Audited Value Difference

Value (e.g., line (e.g., actual (e.g., correct error number) paid amount) paid amount) amount

184 2 $0.00 185 2 $0.00 186 2 $0.00 187 2 $0.00 188 2 $0.00 189 2 $0.00 190 2 $0.00 191 2 $0.00 192 2 $0.00 193 2 $0.00 194 2 $0.00 195 2 $0.00 196 2 $0.00 197 2 $0.00 198 3 3489061 $2,249.80 $2,249.80 $0.00 199 3 3479567 $1,665.54 $1,665.54 $0.00 200 3 3470073 $3,114.49 $3,114.49 $0.00 201 3 3460579 $2,717.87 $2,717.87 $0.00 202 3 3451085 $2,130.75 $2,130.75 $0.00 203 3 3441591 $2,484.80 $2,484.80 $0.00 204 3 3432097 $1,893.30 $1,893.30 $0.00 205 3 3422603 $1,187.55 $1,187.55 $0.00 206 3 3413109 $1,605.08 $1,605.08 $0.00 207 3 3403615 $1,408.95 $1,408.95 $0.00 208 3 3394121 $1,400.00 $1,400.00 $0.00 209 3 3384627 $1,435.00 $1,435.00 $0.00 210 3 3375133 $1,080.00 $1,080.00 $0.00 211 3 3365639 $2,756.25 $2,756.25 $0.00 212 3 3356145 $1,498.04 $1,498.04 $0.00 213 3 3346651 $1,075.00 $1,075.00 $0.00 214 3 3337157 $3,245.62 $3,245.62 $0.00 215 3 3327663 $1,047.12 $1,047.12 $0.00 216 3 3318169 $2,245.30 $2,245.30 $0.00 217 3 3308675 $3,078.18 $3,078.18 $0.00 218 3 3299181 $2,392.69 $2,392.69 $0.00 219 3 3289687 $1,679.08 $1,679.08 $0.00 220 3 3280193 $1,141.00 $1,141.00 $0.00 221 3 3270699 $2,290.00 $2,290.00 $0.00 222 3 3261205 $1,950.00 $1,950.00 $0.00 223 3 3251711 $1,988.80 $1,988.80 $0.00 224 3 3242217 $1,125.00 $1,125.00 $0.00 225 3 3232723 $1,030.00 $1,030.00 $0.00 226 3 3223229 $1,260.00 $1,260.00 $0.00 227 3 3213735 $2,705.40 $2,705.40 $0.00 228 3 3204241 $2,353.55 $1,368.00 $985.55 229 3 3194747 $1,092.84 $1,092.84 $0.00 230 3 3185253 $2,955.29 $2,955.29 $0.00 231 3 3175759 $1,035.00 $1,035.00 $0.00

Other

Identifier Examined

Value Audited Value Difference

Value (e.g., line (e.g., actual (e.g., correct error number) paid amount) paid amount) amount

232 3 $0.00 233 3 $0.00 234 3 $0.00 235 3 $0.00 236 3 $0.00 237 3 $0.00 238 3 $0.00 239 3 $0.00 240 3 $0.00 241 3 $0.00 242 3 $0.00 243 3 $0.00 244 3 $0.00 245 3 $0.00 246 3 $0.00 247 3 $0.00 248 3 $0.00 249 3 $0.00 250 3 $0.00 251 3 $0.00 252 3 $0.00 253 3 $0.00 254 3 $0.00 255 3 $0.00 256 3 $0.00 257 3 $0.00 258 3 $0.00 259 3 $0.00 260 3 $0.00 261 4 $0.00 262 4 $0.00 263 4 $0.00 264 4 $0.00 265 4 $0.00 266 4 $0.00 267 4 $0.00 268 4 $0.00 269 4 589647 $7,151.27 $7,140.00 $11.27 270 4 $0.00 271 4 $0.00 272 4 $0.00 273 4 $0.00 274 4 $0.00 275 4 $0.00 276 4 $0.00 277 4 $0.00 278 4 $0.00 279 4 $0.00

Other

Identifier Examined

Value Audited Value Difference

Value (e.g., line (e.g., actual (e.g., correct error number) paid amount) paid amount) amount

280 4 $0.00 281 4 $0.00 282 4 $0.00 283 4 $0.00 284 4 $0.00 285 4 $0.00 286 4 $0.00 287 4 $0.00 288 4 $0.00 289 4 $0.00 290 4 $0.00 291 4 $0.00 292 4 $0.00 293 4 $0.00 294 4 $0.00 295 4 $0.00 296 4 $0.00 297 4 $0.00 298 4 $0.00 299 4 $0.00 300 4 $0.00 301 4 $0.00 302 4 $0.00 303 4 $0.00 304 4 $0.00 305 4 $0.00 306 4 $0.00 307 4 $0.00 308 5 $0.00 309 5 $0.00 310 5 $0.00 311 5 $0.00 312 5 $0.00 313 5 $0.00 314 5 $0.00 315 5 $0.00 316 5 $0.00 317 5 $0.00 318 5 $0.00 319 5 $0.00 320 5 $0.00 321 5 $0.00 322 5 $0.00 323 5 $0.00 324 5 $0.00 325 5 $0.00 326 5 $0.00 327 5 $0.00

Other

Identifier Examined

Value Audited Value Difference

Value (e.g., line (e.g., actual (e.g., correct error number) paid amount) paid amount) amount

328 5 $0.00 329 5 $0.00 330 5 $0.00 331 5 $0.00 332 5 $0.00 333 5 $0.00 334 5 $0.00 335 5 $0.00 336 5 $0.00 337 5 $0.00 338 5 $0.00 339 5 $0.00 340 5 $0.00 341 5 $0.00 342 5 $0.00 343 5 $0.00 344 5 $0.00 345 5 $0.00 346 5 $0.00 347 5 $0.00 348 5 $0.00 349 5 $0.00 350 5 5326124 1 $16,452.00 $16,452.00 $0.00

ERROR RATE CALCULATION

Instructions:

Ensure the formulas below are pulling the correct amounts and the results make sense.

If the Total Financial Error Rate is 1% or more, enter the Point Estimate and the 90% Lower Confidence Limit from RAT-STATS.

This will provide the total extrapolated adjustment, but this amount still must be allocated to the strata in order to adjust the cost report.

Adjustments should be made to both the costs and statistics reported on the cost report.

Total Net Error Rate

Sample Sample Sample Stratum Total Value Stratum Stratum Limits Size Error Value Error Rate of Universe

1 $0.00 to $249.99 107 $73.53 $2,475.83 3.0% $41,038,006.25 2 $250.00 to $999.99 90 $273.40 $12,886.71 2.1% $38,655,882.65 3 $1,000.00 to $3,499.99 63 $985.55 $64,317.29 1.5% $24,667,061.46 4 $3,500.00 to $14,999.99 47 $11.27 $7,151.27 0.2% $20,224,637.94 5 $15,000.00 & up 44 $0.00 $16,452.00 0.0% $16,126,998.43

TOTAL 351 $1,343.75 $103,283.10 $140,712,586.73

Total Financial Error Rate (Weighted) 1.7%

Is the error rate material? Yes

If material, calculate extrapolated values using RATSTAT or equivalent software:

Best Estimate (Point Estimate)

Report the larger of:

Sample Error $1,343.75

OR

90% Lower Confidence Limit (two-tailed test) for the Total Error