Department of Health and Human Services

Office of Inspector General -- AUDIT

"Ineligible Medicare Payments to Skilled Nursing Facilities Under the Administrative Responsibility of Blue Cross and Blue Shield of Wyoming," (A-05-04-00059)

November 16, 2004


Complete Text of Report is available in PDF format (169 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 Blue Cross and Blue Shield of Wyoming (BCBS of Wyoming), 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 $194,247 of ineligible SNF payments were made under the administrative responsibility of BCBS of Wyoming during calendar years 1997 through 2001.  The overpayments occurred due to the absence of an automated cross-check, within the Centers for Medicare & Medicaid Services (CMS) Common Working File and the FI’s claims processing systems, verifying that a three consecutive day inpatient hospital stay occurred prior to SNF admission.  BCBS of Wyoming has been instructed by the CMS not to seek recovery of overpayments identified during our audit and as a result, no recovery activities have been initiated.