Idaho Mediciad



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

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|Provider Name |      |

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|Provider Number[1] |      |

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|Applicable Periods of Report |      |

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|Management or Provider Personnel Interviewed |      |

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|INTERNAL CONTROL STRUCTURE AND COST REPORT |

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|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? | | |

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|3. |Has the facility terminated its Medicaid Rural Health Clinic or other Medicaid agreements upon approval of FQHC status? | | |

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|4. |Has the chart of accounts changed significantly from the prior year? If so, please provide a copy. | | |

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|5. |Has the organization chart changed from the prior year? If so, please provide a copy. | | |

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Y = Yes, N = No, NA = Not Applicable

[2] 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 |

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| | | |Cash Receipts |      | |

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| | | |Bank Reconciliation |      | |

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| | | |Revenue Journals |      | |

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| | | |Patient Billings and Ledgers |      | |

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| | | |Purchasing |      | |

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| | | |Vendor Payables |      | |

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| | | |Payroll Journals and Reports |      | |

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| | | |Cash Disbursements |      | |

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| | | |Signs Checks |      | |

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| | | |Journal Entries |      | |

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| | | |General Ledger |      | |

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| | | |Financial Statements |      | |

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| | | |Computer Programming |      | |

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| | | |Control/Review |      | |

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| | | |Daily Encounter Logs |      | |

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| | | |Monthly Encounter Summaries |      | |

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| | | |Cost Report Preparation |      | |

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| | | |Independent Accountant |      | |

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| | | |Fixed Asset Control |      | |

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| | | |Inventory |      | |

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| | | |Auto & Travel Reimbursement |      | |

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| | | |Other |      | |

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? | | | |

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|8. |Are all employees required to take annual vacations with someone else performing their duties during that time? | | | |

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|9. |Are there adequate safekeeping facilities for custody of the accounting records such as fireproof storage areas and | | | |

| |restricted access cabinets? | | | |

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|10. |During this fiscal year, have you had any changes in key personnel such as administrator or financial officer? | | | |

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|11. |Are all accounting records retained for a period of not less than seven (7) years? | | | |

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|12. |A. |Was the cost report prepared from the Working Trial Balance (WTB) in our file? | | | |

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| |B. |Were the audit adjustments reflected in the WTB used to prepare the cost report? | | | |

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|13. |A. |Is the WTB submitted with the cost report in agreement with the general ledger? | | | |

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| |B. |Have all the adjusting journal entries been posted to both the general ledger and the WTB? | | | |

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|14. |Was the general ledger used to prepare (audited or unaudited) financial statements? Please provide a copy of the | | | |

| |year-end financial statements. | | | |

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|15. |A. |Are monthly or quarterly financial statements prepared? | | | |

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| |B. |If yes, are they prepared internally or by an independent accountant? | | | |

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| |C. |Are they reviewed by management? | | | |

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|16. |Does management reasonably understand the form and content of the cost reports? | | | |

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|17. |Does management use operating budgets and cash projections? | | | |

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| |If yes, answer the following questions: | | | |

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| |A. |Do the budgets and projections lend themselves to effective comparison with actual results? | | | |

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| |B. |Are material variances reviewed and explained? | | | |

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|18. |Is there a Board of Directors which monitors management activities and entity operations? | | | |

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|19. |Are revenues and expenses reported on the cost report on the accrual basis of accounting? | | | |

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|20. |Are the general ledger and subsidiary ledgers kept current and balanced periodically (monthly)? | | | |

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|21. |Are standard journal entries used to the extent practicable? | | | |

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|22. |Are the journal entries understood and authorized by management? | | | |

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|23. |Are contract service agreements for this facility reimbursable, reasonable, and related to patient care? | | | |

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|24. |Does your facility employ any owners or related parties, or receive any other services or supplies from a related | | | |

| |party or organization? | | | |

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| | |If yes, answer the following questions: | | | |

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| |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? | | | |

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| |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? | | | |

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| |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. | | | |

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|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? | | | |

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| |If yes, answer the following questions: | | | |

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| |A. |Which facilities are involved and what is shared (i.e., hospitals, hotels, apartments, personal care, and | | | |

| | |non-nursing)? | | | |

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| |B. |Do you have an allocation plan and documentation that supports the allocation to this facility? | | | |

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| |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: | | | |

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|26. |During the cost report period, have you had a substantial change in the services you offer? | | | |

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|27. |Are the personal transactions of management completely segregated from the business? | | | |

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|28. | |Have timely payments been made for the following? | | | |

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| |a. |Supplies and services | | | |

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| |b. |Federal and state payroll taxes | | | |

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| |c. |Mortgages and working capital loans | | | |

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| |d. |Lease payments for buildings and equipment | | | |

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|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. | | | |

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|Comments: |

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|1. |Do you have a written capitalization policy? If yes, please provide a copy. | | | |

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|2. |Is property recorded at historical cost? | | | |

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|3. |What is the minimum value for capitalizing assets? | | | |

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|4. |Are the American Hospital Association (AHA) guidelines used to determine the estimated useful life of an asset? | | | |

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|5. |Is depreciation calculated on a straight-line basis? | | | |

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|6. |Do you review repair and maintenance accounts to identify items to be capitalized? | | | |

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|7. |Do you have a copy of a detailed depreciation schedule based on the straight-line method? If yes, please provide a| | | |

| |copy. | | | |

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|8. |Are fixed assets designated between "medical equipment," “dental,” and "other"? | | | |

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|9. |A. |Was there any personal use of facility property? | | | |

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| |B. |If yes, has the personal portion of listed property items been eliminated from the cost report? | | | |

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|10. |A. |Has any property on the cost report been acquired from related parties or organizations? | | | |

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| |B. |If yes, was all profit removed from related party transactions? | | | |

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|11. |A. |Have there been any significant retirements or disposals of property, plant or equipment during the period? | | | |

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| |B. |If yes, was the gain or loss recorded in your records and on the cost report? | | | |

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|12. |Were there any transfers of property, plant and equipment between the facility and related parties? | | | |

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|Comments: |

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|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? | | | |

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| |a. |Working capital borrowings | | | |

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| |b. |Buildings and improvements | | | |

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| |c. |Equipment | | | |

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| |d. |Property not related to patient care | | | |

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|3. |Has interest expense been designated between "medical equipment," "dental equipment," "other equipment," and | | | |

| |"working capital," and reported in appropriate cost centers? | | | |

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|4. |A. |Were there any changes in financing or restructuring of debt during the period? Are there any plans to | | | |

| | |restructure debt? | | | |

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| |B. |If yes, describe business reason. | | | |

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|5. |Is there any financing with related parties on the cost report? | | | |

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|6. |Does your facility fund depreciation? | | | |

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|Comments: |

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|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 | | |

|Radiology | | |

|Laboratory | | |

|Physical Therapy | | |

|Occupational Therapy | | |

|Speech Therapy | | |

|Social Services | | |

|Dental | | |

|Pharmacy | | |

|Other | | |

|Other | | |

|Other | | |

|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. | | | |

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|4. |Are all contractors licensed and/or registered to practice in the state? | | | |

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|5. |Did the facility contract with or receive services from any related parties during the period? | | | |

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|6. |Are the direct costs and related customary charges of each ambulatory service accounted for in an independent cost | | | |

| |center? | | | |

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|Comments: |

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|1. |What type of patients does this facility serve? | | | |

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| |a. |Medicaid |      | | | |

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| |b. |Part A Medicare (Patient) |      | | | |

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| |c. |Part B Medicare (Ancillary) |      | | | |

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| |d. |Veterans Administration |      | | | |

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| |e. |Other Third Party |      | | | |

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| |f. |Private Pay |      | | | |

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|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? | | | |

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|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)? | | | |

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|4. |Are patients charged a nominal fee for services? If so, in what account is income maintained? | | | |

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|5. |A. |Did your facility provide services deemed non-covered by the applicable regulations? | | | |

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| |B. |If yes, please provide a schedule reconciling total costs and encounters associated with non-covered services.| | | |

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|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? | | | |

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|7. |Are encounters maintained for only those services deemed "primary care"? | | | |

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|8. |Please provide a schedule showing encounters, by month and by payor source, that agrees to the cost report. | | | |

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|9. |Are EPSDT encounters designated and identified with a unique encounter code? | | | |

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|10. |Are the Medicaid encounters reported on the monthly billings to the Medicaid intermediary reconciled to the monthly | | | |

| |encounter reports? | | | |

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|11. |Do you apply your charge schedules uniformly to all patients? | | | |

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|12. |A. |Does your facility rent space to others? | | | |

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| |B. |If yes, has the rental revenue been offset against related expense? | | | |

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|13. |Has all interest and other investment income been offset against interest expense? | | | |

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|14. |A. |Do you have any fund-raising expenses? | | | |

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| |B. |If yes, have such expenses been eliminated from the cost report? | | | |

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|15. |Please provide a brief description of the type of dental services offered by your facility. Examples include | | | |

| |cleanings, fillings, dentures, bridges, etc. | | | |

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|Comments: |

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|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 | |

|Lease Agreements | | | | |

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|2. |Does your facility lease any equipment or buildings? | | | |

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|3. |Were costs associated with off-site physician services, outside the scope of allowable services of an FQHC, incurred| | | |

| |during the period? | | | |

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|4. |A. |Do you have any arrangements with volunteer workers who provide services which are usually provided by paid | | | |

| | |employees? | | | |

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| |B. |If yes, please provide a list of volunteer personnel, including the amount of imputed salary and any other | | | |

| | |benefits provided. | | | |

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|5. |Does your facility have any non-reimbursable cost centers? | | | |

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|6. |Does your facility self-insure for any of the following? | | | |

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| |a. |Malpractice Insurance |      | | | |

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| |b. |Unemployment Insurance |      | | | |

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| |c. |Casualty Losses |      | | | |

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|7. |Does your facility have to pay any taxes other than the usual payroll and property taxes? If yes, what is the | | | |

| |nature of these taxes? | | | |

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|8. |Did your facility incur any costs for employee recruitment? | | | |

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|9. |Did your facility incur any legal expenses? | | | |

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|10. |Does your facility obtain workers' compensation insurance from the State? | | | |

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|11. |Did your facility suffer any of the following? | | | |

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| |a. |Casualty losses |      | | | |

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| |b. |Theft losses |      | | | |

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|12. |Does your purchasing department record purchases net of any applicable discount? | | | |

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|13. |A. |What type of advertising expense does your facility have? | | | |

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| |B. |In which account(s) is this expense recorded? | | | |

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|Comments: |

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|1. Please provide copies of the following home office (HO) items, unless any item is not applicable or has been previously provided and has not changed: |

| | |Copy |Previously | |

| | |Enclosed |Provided |N/A | |

|Medicare HO Cost Statement (HCA-287) | | | | |

|HO Working Trial Balance | | | | |

|2. |Do you have a flow chart or other summary showing various operations and the corporate structure of the entire | | | |

| |entity? If yes, please provide a copy. | | | |

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|3. |Do you have an allocation plan? If yes, please provide a copy. | | | |

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|4. |Can you summarize the allocation method used for general or pooled expense accounts? (Even if an allocation plan is | | | |

| |available.) | | | |

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| |a. |From entity-wide activities to total health care activities. | | | |

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| |b. |From total health care activities to all FQHCs. | | | |

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| |c. |From all FQHCs to FQHCs in this state. | | | |

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| |d. |Alternative question for simplified chain operations (mark above three questions NA): Are all activities | | | |

| | |related to patient care and are all pooled costs allocated to individual facilities on an encounter basis? | | | |

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|5. |Is there a written document that summarizes major allocation statistics? Examples: schedule of encounters by state| | | |

| |or facility, compilation of allocation by independent accountant, or summary of Medicare allocations. If yes, | | | |

| |please provide a copy. | | | |

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|6. |Does the chain or home office have any of the following? | | | |

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| |a. |Loans to Facility | | | |

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| |b. |Investment Income | | | |

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| |c. |Management Fees Charged to Facility | | | |

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| |d. |Insurance Purchased for Facility | | | |

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| |e. |Fund Raising Expenses | | | |

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|7. |A. |Were there any attempts to acquire or dispose of facilities during the cost reporting period? | | | |

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| |B. |If yes, were acquisition and/or disposal costs, including travel, legal costs and feasibility studies, | | | |

| | |eliminated from operating expenses for purposes of Medicaid cost determinations? | | | |

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|8. |Have steps been taken to eliminate expenses in the following areas? | | | |

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| |Medicare Section and Item | | | |

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| |a. |2136.2 |Advertising Costs (Promotional advertising is not allowable.) | | |

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| |b. |2122.4 |Franchise Taxes | | |

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| |c. |2105.1 |Non-competition Agreements (Goodwill amortization is not allowable.) | | |

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| |d. |2130 |Life Insurance Premiums (If provider is a direct or indirect beneficiary, it is not allowable unless | | |

| | | |required by lending institution.) | | |

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| |e. |2138.3 |Membership Costs (Business, technical or civic are allowable; social, fraternal or country club are not | | |

| | | |allowable.) | | |

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|9. |A. |Do you have any knowledge of disallowed cost or potentially disallowed cost by any state Medicaid agency or | | | |

| | |Medicare intermediary during the last two years? | | | |

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| |B. |If yes, may we review exit conference issues, correspondence and other material relating to such items? | | | |

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|10. |Have all payment requirements on accounts payable and outstanding loans been met? | | | |

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|11. |Has there been any restructuring of debts during the year, or are there any plans for restructuring debt? | | | |

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|Comments: |

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|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 | |

|Federal Form 941s | | | | |

|2. |Please provide the names and positions of the five highest paid employees. | | | |

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|NAME | |POSITION | |DEPARTMENT |

|      | |Administrator | |      |

|      | |Director of Nursing | |      |

|      | |      | |      |

|      | |      | |      |

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|3. |Are all employee benefits reported in the employee benefits section of the cost report? | | | |

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|4. |Is there any non-taxable compensation included in cost report salaries (i.e., would not be reported on Form 941). | | | |

| |Please provide payroll tax files for our review. | | | |

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|5. |Do job descriptions exist that detail specific responsibilities for key personnel? | | | |

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|6. |Does your facility have an employee pension plan? | | | |

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|7. |Does your facility have a deferred compensation plan? | | | |

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|8. |Is documentation maintained to designate physician time between direct patient care and administrative activities? | | | |

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|9. |Have any payments been made under the National Health Service Corps reimbursement program? | | | |

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|Comments: |

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I hereby certify that I have answered the questions on pages 1 through 19 of this document regarding the internal controls and cost reporting practices of: [key facility name(s) and number(s) below]:

     

for the period beginning       and ending       , and that, to the best of my knowledge and belief, the answers are true, correct, and complete.

|Signed | | |      |

| |Officer or Administrator of Provider(s) | |Title |

| | | | |

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| |Print Name | |Date |

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Print entire form, then sign and date this Certification page.

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