Medicare Compliance & Reimbursement

Admissions on or after the effective date of a denial of payment remedy pose big problems for skilled nursing facilities if federal funds are in play. Yet uniform application of the sanction is turning out to be less than foolproof.

A May 5 HHS Office of InspectorGeneral audit of the denial of payment remedy for new admissions in Ohio nursing facilities showed that 9 facilities in 46 collected $25,976 in unallowable reimbursement between 1999 and 2001 after sanctions were in place. However, the estimate was downgraded to $17, 796 after Ohio countered that over $10,000 in payments were accurate because the residents'stay did not meet the definition of "new admission." In those cases, the Medicaid payment was initiated for an ongoing private pay resident who converted to Medicaid during the denial of payment time span.

To read the report, titled "Audit of Nursing Homes and Denial of Payment Remedies, State of Ohio October 1, 1999 Through September 30, 2001 -- Ohio Department of Job and Family Services" (A-05-03-00037), go to http://oig.hhs.gov/oas/reports/region5/50300037.pdf.

Lesson Learned: Sanctioned facilities would do well to brush up on the details of Medicare rules surrounding denial of payment remedies for new admissions.