INTERNAL CONTROL STRUCTURE AND COST REPORT
MYERS AND STAUFFER LC
Certified Public Accountants
Idaho Medicaid
Internal Control and Cost Reporting Questionnaire
Federally Qualified Health Center
Interview Questionnaire of Management's Representations
Provider NameProvider Number[1]
Applicable Periods of Report
Management or Provider Personnel Interviewed
INTERNAL CONTROL STRUCTURE AND COST REPORT
1. Please provide copies of the following items, unless any item is not applicable or has been previously provided and has not changed:
Copy / Previously
Enclosed / Provided / N/A
Organization Chart
Independent Audit Adjustments
Financial Statements (audited/unaudited)
2. / Has the license for this facility been changed, revoked, or the subject of any investigations? / Choose below:YNNA
3. / Has the facility terminated its Medicaid Rural Health Clinic or other Medicaid agreements upon approval of FQHC status? / Choose below:YNNA
4. / Has the chart of accounts changed significantly from the prior year? If so, please provide a copy. / Choose below:YNNA
5. / Has the organization chart changed from the prior year? If so, please provide a copy. / Choose below:YNNA
Y = Yes, N = No, NA = Not Applicable
If this IQ is applicable to more than one facility, insert facility names or attach list of facilities. In these cases, the term "this facility" means all such facilities, unless otherwise conditioned by management being interviewed.
6. / Who performs the following functions, are they computerized, and where are they performed?Originating / Mgt./Supervisor
Computer / Location / Performs Function / Approval
Choose below:YN / Choose below:FIH / Cash Receipts / Choose below:YNNA
Choose below:FIH / Bank Reconciliation / Choose below:YNNA
Choose below:YN / Choose below:FIH / Revenue Journals / Choose below:YNNA
Choose below:YN / Choose below:FIH / Patient Billings and Ledgers / Choose below:YNNA
Choose below:FIH / Purchasing / Choose below:YNNA
Choose below:YN / Choose below:FIH / Vendor Payables / Choose below:YNNA
Choose below:YN / Choose below:FIH / Payroll Journals and Reports / Choose below:YNNA
Choose below:YN / Choose below:FIH / Cash Disbursements / Choose below:YNNA
Choose below:FIH / Signs Checks / Choose below:YNNA
Choose below:FIH / Journal Entries / Choose below:YNNA
Choose below:YN / Choose below:FIH / General Ledger / Choose below:YNNA
Choose below:YN / Choose below:FIH / Financial Statements / Choose below:YNNA
Choose below:FIH / Computer Programming / Choose below:YNNA
Choose below:FIH / Control/Review / Choose below:YNNA
Choose below:YN / Choose below:FIH / Daily Encounter Logs / Choose below:YNNA
Choose below:YN / Choose below:FIH / Monthly Encounter Summaries / Choose below:YNNA
Choose below:YN / Choose below:FIH / Cost Report Preparation / Choose below:YNNA
Choose below:FIH / Independent Accountant / Choose below:YNNA
Choose below:YN / Choose below:FIH / Fixed Asset Control / Choose below:YNNA
Choose below:YN / Choose below:FIH / Inventory / Choose below:YNNA
Choose below:FIH / Auto & Travel Reimbursement / Choose below:YNNA
Choose below:FIH / Other / Choose below:YNNA
F = Facility, I = Independent Contractor, H = Home/Central Office
7. / Are accounting functions separated by segregation of duties to reduce opportunities that allow any person to be in a position to perpetrate or conceal errors or irregularities in the normal course of their duties? / Choose below:YNNA8. / Are all employees required to take annual vacations with someone else performing their duties during that time? / Choose below:YNNA
9. / Are there adequate safekeeping facilities for custody of the accounting records such as fireproof storage areas and restricted access cabinets? / Choose below:YNNA
10. / During this fiscal year, have you had any changes in key personnel such as administrator or financial officer? / Choose below:YNNA
11. / Are all accounting records retained for a period of not less than seven (7) years? / Choose below:YNNA
12. / A. / Was the cost report prepared from the Working Trial Balance (WTB) in our file? / Choose below:YNNA
B. / Were the audit adjustments reflected in the WTB used to prepare the cost report? / Choose below:YNNA
13. / A. / Is the WTB submitted with the cost report in agreement with the general ledger? / Choose below:YNNA
B. / Have all the adjusting journal entries been posted to both the general ledger and the WTB? / Choose below:YNNA
14. / Was the general ledger used to prepare (audited or unaudited) financial statements? Please provide a copy of the year-end financial statements. / Choose below:YNNA
15. / A. / Are monthly or quarterly financial statements prepared? / Choose below:YNNA
B. / If yes, are they prepared internally or by an independent accountant? / Choose below:InternallyIndependent Accountant
C. / Are they reviewed by management? / Choose below:YNNA
16. / Does management reasonably understand the form and content of the cost reports? / Choose below:YNNA
17. / Does management use operating budgets and cash projections? / Choose below:YNNA
If yes, answer the following questions:
A. / Do the budgets and projections lend themselves to effective comparison with actual results? / Choose below:YNNA
B. / Are material variances reviewed and explained? / Choose below:YNNA
18. / Is there a Board of Directors which monitors management activities and entity operations? / Choose below:YNNA
19. / Are revenues and expenses reported on the cost report on the accrual basis of accounting? / Choose below:YNNA
20. / Are the general ledger and subsidiary ledgers kept current and balanced periodically (monthly)? / Choose below:YNNA
21. / Are standard journal entries used to the extent practicable? / Choose below:YNNA
22. / Are the journal entries understood and authorized by management? / Choose below:YNNA
23. / Are contract service agreements for this facility reimbursable, reasonable, and related to patient care? / Choose below:YNNA
24. / Does your facility employ any owners or related parties, or receive any other services or supplies from a related party or organization? / Choose below:YNNA
If yes, answer the following questions:
A. / Do you maintain adequate records, including timesheets or activity reports and allocation rationale, to document the type of patient related services rendered and the hours worked? / Choose below:YNNA
B. / Is the amount paid to related parties or organizations eliminated and replaced with the related party or organization's actual cost substituted in its place? / Choose below:YNNA
C. / Have you applied for an exception to the related party rules per 42 CFR 413.17(d)?
If yes, please provide supporting documentation showing that the criteria under this section have been met. / Choose below:YNNA
25. / Do you or any of the facility's owners and related parties or organizations have an interest in any other health care facilities or organizations which could lead to sharing property or personnel with this facility? / Choose below:YNNA
If yes, answer the following questions:
A. / Which facilities are involved and what is shared (i.e., hospitals, hotels, apartments, personal care, and non-nursing)? / Choose below:YNNA
B. / Do you have an allocation plan and documentation that supports the allocation to this facility? / Choose below:YNNA
C. / Were any costs included in the cost report incurred on behalf of other facilities? If yes, indicate in which WTB account(s) these costs are included: / Choose below:YNNA
26. / During the cost report period, have you had a substantial change in the services you offer? / Choose below:YNNA
27. / Are the personal transactions of management completely segregated from the business? / Choose below:YNNA
28. / Have timely payments been made for the following?
a. / Supplies and services / Choose below:YNNA
b. / Federal and state payroll taxes / Choose below:YNNA
c. / Mortgages and working capital loans / Choose below:YNNA
d. / Lease payments for buildings and equipment / Choose below:YNNA
29. / Have you received correspondence from the IRS or any state Department(s) of Revenue concerning late payments and penalties on payroll taxes? If yes, please provide copies. / Choose below:YNNA
Comments:
Rev 08/15 4
PROPERTY, EQUIPMENT AND DEPRECIATION
1. / Do you have a written capitalization policy? If yes, please provide a copy. / Choose below:YNNA2. / Is property recorded at historical cost? / Choose below:YNNA
Choose below:YNNA
3. / What is the minimum value for capitalizing assets?
4. / Are the American Hospital Association (AHA) guidelines used to determine the estimated useful life of an asset? / Choose below:YNNA
5. / Is depreciation calculated on a straight-line basis? / Choose below:YNNA
6. / Do you review repair and maintenance accounts to identify items to be capitalized? / Choose below:YNNA
7. / Do you have a copy of a detailed depreciation schedule based on the straight-line method? If yes, please provide a copy. / Choose below:YNNA
8. / Are fixed assets designated between "medical equipment," “dental,” and "other"? / Choose below:YNNA
9. / A. / Was there any personal use of facility property? / Choose below:YNNA
B. / If yes, has the personal portion of listed property items been eliminated from the cost report? / Choose below:YNNA
10. / A. / Has any property on the cost report been acquired from related parties or organizations? / Choose below:YNNA
B. / If yes, was all profit removed from related party transactions? / Choose below:YNNA
11. / A. / Have there been any significant retirements or disposals of property, plant or equipment during the period? / Choose below:YNNA
B. / If yes, was the gain or loss recorded in your records and on the cost report? / Choose below:YNNA
12. / Were there any transfers of property, plant and equipment between the facility and related parties? / Choose below:YNNA
Comments:
Rev 08/15 4
NOTES PAYABLE AND INTEREST EXPENSE
1. Please provide copies of the following items, unless any item is not applicable or has been previously provided and has not changed:Copy / Previously
Enclosed / Provided / N/A
Loan Documents
Amortization Schedules
2. / Do you have any of the following types of debts?
a. / Working capital borrowings / Choose below:YNNA
b. / Buildings and improvements / Choose below:YNNA
c. / Equipment / Choose below:YNNA
d. / Property not related to patient care / Choose below:YNNA
3. / Has interest expense been designated between "medical equipment," "dental equipment," "other equipment," and "working capital," and reported in appropriate cost centers? / Choose below:YNNA
4. / A. / Were there any changes in financing or restructuring of debt during the period? Are there any plans to restructure debt? / Choose below:YNNA
B. / If yes, describe business reason.
5. / Is there any financing with related parties on the cost report? / Choose below:YNNA
6. / Does your facility fund depreciation? / Choose below:YNNA
Comments:
Rev 08/15 4
CONTRACTOR AND OUTSIDE SERVICES
1. Please provide copies of the following items, unless any item is not applicable or has been previously provided and has not changed:Copy / Previously
Enclosed / Provided / N/A
Contract Agreements
2. / Did your facility provide any the following services? If yes, were the services provided by an independent contractor?
Ancillary / Provided Service / Contracted
Physician Services / Choose below:YN / Choose below:YNNA
Radiology / Choose below:YN / Choose below:YNNA
Laboratory / Choose below:YN / Choose below:YNNA
Physical Therapy / Choose below:YN / Choose below:YNNA
Occupational Therapy / Choose below:YN / Choose below:YNNA
Speech Therapy / Choose below:YN / Choose below:YNNA
Social Services / Choose below:YN / Choose below:YNNA
Dental / Choose below:YN / Choose below:YNNA
Pharmacy / Choose below:YN / Choose below:YNNA
Other / Choose below:YN / Choose below:YNNA
Other / Choose below:YN / Choose below:YNNA
Other / Choose below:YN / Choose below:YNNA
3. / Do contract agreements state that subcontractors shall retain related records for at least five years after the provider's fiscal year-end in accordance with IDAPA 16.03.09.205.01.c? Please provide copies of contract agreements, if not previously submitted. / Choose below:YNNA
4. / Are all contractors licensed and/or registered to practice in the state? / Choose below:YNNA
5. / Did the facility contract with or receive services from any related parties during the period? / Choose below:YNNA
6. / Are the direct costs and related customary charges of each ambulatory service accounted for in an independent cost center? / Choose below:YNNA
Comments:
Rev 08/15 4
REVENUE AND ENCOUNTER LOG
1. / What type of patients does this facility serve?a. / Medicaid / Choose below:YNNA
b. / Part A Medicare (Patient) / Choose below:YNNA
c. / Part B Medicare (Ancillary) / Choose below:YNNA
d. / Veterans Administration / Choose below:YNNA
e. / Other Third Party / Choose below:YNNA
f. / Private Pay / Choose below:YNNA
2. / Did your facility receive revenue under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, Presumptive Eligibility Screenings, or any other state or federal program? / Choose below:YNNA
3. / Does your facility receive any payments for services on a fee-for-service basis (i.e., global payments for O.B., E.R. physician payments)? / Choose below:YNNA
4. / Are patients charged a nominal fee for services? If so, in what account is income maintained? / Choose below:YNNA
5. / A. / Did your facility provide services deemed non-covered by the applicable regulations? / Choose below:YNNA
B. / If yes, please provide a schedule reconciling total costs and encounters associated with non-covered services.
6. / Is contact with more than one health professional, or multiple contacts with the same professional in the same day for the same illness or injury, counted as a single encounter? / Choose below:YNNA
7. / Are encounters maintained for only those services deemed "primary care"? / Choose below:YNNA
8. / Please provide a schedule showing encounters, by month and by payor source, that agrees to the cost report.
9. / Are EPSDT encounters designated and identified with a unique encounter code? / Choose below:YNNA
10. / Are the Medicaid encounters reported on the monthly billings to the Medicaid intermediary reconciled to the monthly encounter reports? / Choose below:YNNA
11. / Do you apply your charge schedules uniformly to all patients? / Choose below:YNNA
12. / A. / Does your facility rent space to others? / Choose below:YNNA
B. / If yes, has the rental revenue been offset against related expense? / Choose below:YNNA
13. / Has all interest and other investment income been offset against interest expense? / Choose below:YNNA
14. / A. / Do you have any fund-raising expenses? / Choose below:YNNA
B. / If yes, have such expenses been eliminated from the cost report? / Choose below:YNNA
15. / Please provide a brief description of the type of dental services offered by your facility. Examples include cleanings, fillings, dentures, bridges, etc.
Comments:
Rev 08/15 4