Corporate Compliance

Gov’t audit insider: Ineligible Medicare payments to SNFs

Healthcare Auditing Weekly, December 2, 2003

The Office of Inspector General's (OIG) audit objective was to determine the extent of ineligible Medicare skilled nursing facility (SNF) payments made under the administrative responsibility of Anthem Health Plans of Maine, Inc. The OIG performed the following steps:

1. Limited testing to determine whether any other sources supported the required inpatient stay. Of note: The OIG's substantial data analysis established a database of SNF claims that were paid, even though CMS' National Claims History File did not support the existence of a preceding three-day inpatient hospital stay.

2. Selected a statistical sample of 200 SNF stays from the Anthem database (reimbursed at $1,128,074) and compared the SNF admission to inpatient information on the Common Working File (CWF) system.

3. Reviewed for each of the 200 SNF stays selected in the sample the inpatient listing (INPL) claims screen. The OIG did this for the various CWF host sites to help it identify any inpatient stays omitted from the database that would make the SNF stay eligible for reimbursement.

4. Used the OIG's RAT-STATS Unrestricted Variable Appraisal Program to project the amount of SNF payments eligible for Medicare reimbursement.

5. Used the "difference estimator" estimation method to measure the amount of eligible Medicare reimbursement that was inadvertently included in the database. Note: The database was intended to quantify only ineligible Medicare reimbursement.

6. Used the difference estimator to adjust the database of ineligible SNF payments and then calculated the upper and lower limits at the 90% confidence level.

Click here to read the audit report "Ineligible Medicare Payments to Skilled Nursing Facilities Under the Administrative Responsibility of Anthem Health Plans of Maine, Inc."


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