Medicare Monthly Review Details

New Uniform Thresholds for Determining Low Medicare Utilization Providers

Effective for all cost reports received on or after 6/19/2020, the MACs are instructed to use the following defined “Low Medicare Utilization Thresholds” compared to total reimbursement amounts to determine whether a provider qualifies to file a low utilization cost report in accordance with PRM 15-2, Section 110:

  • Federally Qualified Health Clinics (FQHCs): $50,000
  • Rural Health Clinics (RHCs): $50,000
  • Community Mental Health Clinics (CMHCs): $15,000 CMHCs with no outlier payments reported on the PS&R qualify for low utilization.
  • All Other Providers: $200,000.This includes hospital and non-hospital provider types.

Note 1: Total Reimbursement is the sum of the current interim payments on the PS&R, total bi- weekly payments (including Periodic Interim Payments) and total lump sum adjustments.

Note 2: The above thresholds will be applied to the cost report being submitted for the entire provider complex (family). This means if a hospital cost report is being submitted with a provider-based FQHC, the Low Medicare Utilization threshold used will be the $200,000 hospital threshold amount; it will not be $250,000 (which would be the hospital $200,000 threshold plus the FQHC $50,000 threshold).