Medicare Compliance & Reimbursement

Nursing homes could face overpayment demands. 

Are skilled nursing facilities across the country inappropriately collecting Medicare reimbursement for patients who haven't had a three-consecutive-day hospital stay within 30 days of admission?

The HHS Office of Inspector General thinks so, and has undertaken a series of reports examining the issue at Medicare contractors across the country. In the latest pair of reports - "Ineligible Medicare Payments to Skilled Nursing Facilities Under the Administrative Responsibility of TriSpan Health Services" (A-05-03-00050) and "Ineligible Medicare Payments to Skilled Nursing Facilities Under the Administrative Responsibility of Blue Cross and Blue Shield of Arizona, Inc." (A-05-03-00072) - the OIG found that TriSpan should recover $4.7 million from SNFs and BCBSAZ should recoup $1.7 million.

This sort of overpayment collection is very complicated for contractors, however, and it looks like the Centers for Medicare & Medicaid Services is working on a nationwide fix. In a response to the report, TriSpan notes that CMS told it to suspend overpayment activities for now. "Since the issues raised appear to be of a national nature, the CMS will furnish all contractors with instructions on how to proceed in a uniform manner," TriSpan reports.

To see the Trispan report, go to http://oig.hhs.gov/oas/reports/region5/50300050.pdf. To see the BCBSAZ report, go to http://oig.hhs.gov/oas/reports/region5/50300072.htm.

Lesson Learned: Long-term care facilities should make sure they document a three-day hospital stay for all of their Medicare patients.