Ineligible Medicare Payments To Skilled Nursing Facilities Under the Administrative Responsibility of Rhode Island Medicare Services

EXECUTIVE SUMMARY:

The objective of this audit was to determine the extent of ineligible Medicare Skilled Nursing Facility (SNF) payments, attributable to Rhode Island Medicare Services, 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 $510,163 of ineligible SNF payments were made under the administrative responsibility of Rhode Island Medicare Services 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 Common Working File and the Fiscal Intermediary's (FI) claims processing systems, verifying that a three consecutive day inpatient hospital stay occurred prior to SNF admission.  In their response, Rhode Island Medicare Services cited a CMS memorandum which instructed all Medicare FIs to suspend recovery efforts related to the OIG audit of ineligible SNF payments.