Corporate Compliance

GOV’T AUDIT INSIDER: Oregon overclaimed more than $230.5 million

Healthcare Auditing Weekly, March 22, 2005

Oregon incorrectly calculated upper payment limits (UPL) for non-state government nursing facilities for fiscal years (FY) 2002 and 2003, according to an OIG audit report. As a result, Oregon's Medicaid payments for non-state government nursing facilities exceeded the allowed amount by more than $230.5 million. The UPL is an estimate of the amount that would be paid for Medicaid services under Medicare payment principles. The OIG recommends that Oregon reduce the claimed expenses and calculate UPLs according to federal regulations to avoid overpayments.

During the audit, the OIG did the following:

  • Held discussions with CMS staff

  • Reviewed applicable records and documents

  • Interviewed key Oregon personnel

  • Reviewed available records supporting Oregon's UPL calculations and estimated basic Medicaid and UPL payments

  • Calculated the UPLs for FYs 2000 and 2001 using data from Oregon to determine the excess amount for future periods

  • Used data provided by Oregon in calculating the FY 2002 UPL

  • Analyzed Oregon's FY 2003 UPL calculation

  • Reviewed Oregon's calculation

  • Estimated the UPLs for FYs 2004 and 2005 and compared them with Oregon's estimated UPL payments for those years

  • Traced UPL payments to CMS-64 quarterly expenditure reports

    Click here to read the audit report, "Audit of Oregon's Medicaid Upper-Payment-Limit Requirements for Non-State Government Nursing Facilities for State Fiscal Years 2002 and 2003," (A-09-03-00055) issued February 18.

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