Department of Health and Human Services

Office of Inspector General -- AUDIT

"Ineligible Medicare Payments To Skilled Nursing Facilities Under The Administrative Responsibility of Anthem Health Plans of New Hampshire, Inc.," (A-05-04-00058)

July 15, 2004


Complete Text of Report is available in PDF format (161 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


EXECUTIVE SUMMARY:

The objective of this audit was to determine the extent of ineligible Medicare Skilled Nursing Facility (SNF) payments, attributable to Anthem Health Plans of New Hampshire, Inc. (Anthem), contained in a database of payments made under the administrative responsibility of nine Medicare Fiscal Intermediaries (FI’s).  Our review of the database estimated that $206,495 of ineligible SNF payments were made under the administrative responsibility of Anthem during calendar years 1997 through 2001.  The overpayments occurred due to the absence of an automated cross-check, within the Centers for Medicare and Medicaid Services Common Working File and the Fiscal Intermediary’s (FI) claims processing systems, verifying that a three consecutive day inpatient hospital stay occurred prior to SNF admission.  Anthem will not initiate recovery actions on the ineligible payments within our database due to a CMS memorandum which instructed all FIs not to initiate any recovery actions.