Ineligible Medicare Payments to Skilled Nursing Facilities Under the Administrative Responsibility of Blue Cross and Blue Shield of Georgia, Inc.

EXECUTIVE SUMMARY:

The objective of this audit was to determine the extent of ineligible Medicare Skilled Nursing Facility (SNF) payments contained in our database of payments made under the administrative responsibility of Blue Cross and Blue Shield of Georgia, Inc. (BCBS of Georgia). We estimated that $1.1 million of ineligible SNF payments were made during calendar years 1997 through 2001. The overpayments occurred because of the absence of an automated cross-check, within the Centers for Medicare & Medicaid Services Common Working File and the Fiscal Intermediary's claims processing systems, verifying that a three consecutive day inpatient hospital stay occurred prior to SNF admission.