The Office of Inspector General has found skilled nursing facilities erroneously billed one-quarter of their claims in 2009, resulting in $1.5 billion in inappropriate Medicare payments.
The OIG based its findings on a stratified sample of SNF claims from 2009, for which reviewers determined whether information reported on the Minimum Data Set was consistent with that reported on medical records. MDS is a standardized tool used by SNFs to assess each Medicare beneficiary and classify beneficiaries into resource utilization groups, which determine how much Medicare pays SNFs.
The majority of the erroneous claims were upcoded, according to the OIG. Many of those upcodes were for ultrahigh therapy. Remaining erroneous claims were downcoded or did not meet Medicare coverage requirements. Also, the OIG found SNFs misreported information on the MDS for 47 percent of claims. Therapy was commonly misreported, and that information largely determines the beneficiary's RUG and amount Medicare reimburses the SNF.
The OIG recommended CMS increase and expand reviews of SNF claims, use its fraud prevention system to identify SNFs billing for higher-paying RUGs and follow-up on SNFs that billed erroneously, among other recommendations — all with which CMS concurred.
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The OIG based its findings on a stratified sample of SNF claims from 2009, for which reviewers determined whether information reported on the Minimum Data Set was consistent with that reported on medical records. MDS is a standardized tool used by SNFs to assess each Medicare beneficiary and classify beneficiaries into resource utilization groups, which determine how much Medicare pays SNFs.
The majority of the erroneous claims were upcoded, according to the OIG. Many of those upcodes were for ultrahigh therapy. Remaining erroneous claims were downcoded or did not meet Medicare coverage requirements. Also, the OIG found SNFs misreported information on the MDS for 47 percent of claims. Therapy was commonly misreported, and that information largely determines the beneficiary's RUG and amount Medicare reimburses the SNF.
The OIG recommended CMS increase and expand reviews of SNF claims, use its fraud prevention system to identify SNFs billing for higher-paying RUGs and follow-up on SNFs that billed erroneously, among other recommendations — all with which CMS concurred.
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