Ineligible Medicare Payments To Skilled Nursing Facilities Under the Administrative Responsibility of Cooperativa de Seguros de Vida de Puerto Rico

EXECUTIVE SUMMARY:

The objective of our audit was to determine the extent of ineligible Medicare Skilled Nursing Facility (SNF) payments, attributable to Cooperativa de Seguros de Vida de Puerto Rico (Cooperativa), contained in a database of payments made under the administrative responsibility of nine Medicare Fiscal Intermediaries (FIs).  Our review of the database estimated that $25,690 of ineligible SNF payments were made under the administrative responsibility of Cooperativa 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 FIs claims processing systems, verifying that a three consecutive day inpatient hospital stay occurred prior to SNF admission.  Cooperativa has been instructed by the CMS not to seek recovery of overpayments identified during our audit and as a result, no recovery activities have been initiated.