Ineligible Medicare Payments to Skilled Nursing Facilities Under the Administrative Responsibility of Chisholm Administrative Services

EXECUTIVE SUMMARY:

The objective of this audit was to determine the extent of ineligible Medicare Skilled Nursing Facility (SNF) payments, attributable to Chisholm Administrative Services (Chisholm), 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 $383,456 of ineligible SNF payments were made under the administrative responsibility of Chisholm 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 (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.  Chisholm will not initiate recovery actions on the ineligible payments within our database due to a CMS memorandum instructing all FIs not to initiate any recovery actions.