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Illinois Nursing Home Claims Lack Hospital Stay

Wed, 11/08/2000 - 1:00am — Karen Stevenson
Description: 

The Office of the Inspector General of the Department of Health and Human Services (OIG-HHS) investigated Medicaid payment to skilled nursing facilities in Illinois. A Medicare skilled nursing facility (SNF) claim generally qualifies for reimbursement only if the SNF stay was preceded by an inpatient hospital stay of at least 3 days and the hospital discharge was within 30 days of the SNF admission. This final report estimates, based on a statistical sample, that Medicare inappropriately paid Illinois providers $900,000 for SNF services during calendar year 1996 because the 3-day hospital stay requirement was not met.

This occurred primarily because the fiscal intermediary did not cross check SNF claims against hospital claims. The fiscal intermediaries involved in the sample reviewed the medical records and data for the sampled claims and concurred that the SNF stays were ineligible for Medicare reimbursement and indicated they would request refunds for each incorrect payment identified.

The Office of the Inspector General of the Department of Health and Human Services (OIG-HHS) investigated Medicaid payment to skilled nursing facilities in Illinois. A Medicare skilled nursing facility (SNF) claim generally qualifies for reimbursement only if the SNF stay was preceded by an inpatient hospital stay of at least 3 days and the hospital discharge was within 30 days of the SNF admission. This final report estimates, based on a statistical sample, that Medicare inappropriately paid Illinois providers $900,000 for SNF services during calendar year 1996 because the 3-day hospital stay requirement was not met.

This occurred primarily because the fiscal intermediary did not cross check SNF claims against hospital claims. The fiscal intermediaries involved in the sample reviewed the medical records and data for the sampled claims and concurred that the SNF stays were ineligible for Medicare reimbursement and indicated they would request refunds for each incorrect payment identified.