Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of Fee-for-Service Payments for Medicare Beneficiaries Enrolled in Managed Care Risk Plans," (A-07-05-01016)

November 1, 2006

PDF File Complete Text of Report is available in PDF format (376 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.

EXECUTIVE SUMMARY:

Our objective was to determine whether the fiscal intermediaries complied with Federal regulations in making fee-for-service payments to hospitals for inpatient services furnished to Medicare managed care organization (MCO) beneficiaries. Fiscal intermediaries did not always comply with Federal regulations in making fee-for-service payments to hospitals for inpatient services furnished to Medicare MCO beneficiaries. The intermediaries incorrectly paid 803 fee‑for‑service inpatient claims in calendar year 2003 and 2004 for beneficiaries who were enrolled in MCOs. We recommended that CMS: (1) direct the fiscal intermediaries to recoup the $4.6 million of duplicate payments and (2) periodically compare the Group Health Plan with the Common Working File, reconcile any discrepancies in enrollment data, and have the fiscal intermediaries take necessary action on apparent duplicate payments. CMS agreed.