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For the period July 2, 2002, through May 31, 2003, Medicare overpaid Heartland Health Care (Heartland) $158,000 for 47 claims (out of 50 claims totaling $260,000) for skilled services that were not (1) medically necessary at the level provided in a skilled nursing facility (SNF) and/or at the Resource Utilization Group (RUG) level claimed or (2) adequately supported by medical documentation. Medicare pays SNFs a daily rate to cover skilled services provided to Medicare beneficiaries. For billing purposes, SNFs complete an assessment form that places a patient in a specific payment group, known as a RUG, based on the patientís care and resource needs.
We recommended that Heartland refund to the Medicare program $158,000 in overpayments and provide training to its staff on SNF medical necessity and documentation requirements. Heartland disagreed with our findings and took issue with many aspects of the review. However, we relied on the knowledge and expertise of medical reviewers from a Medicare program safeguard contractor; therefore, we stand by the findings and recommendations.